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THE  TREATMENT 


OF 


FRACTURES 


WITH  NOTES  UPON  A  FEW 
COMMON    DISLOCATIONS 


BY 

CHARLES    LOCKE    SCUDDER,    M.D. 

SURGEON  TO  THE  MASSACHUSETTS  GENERAL   HOSPITAL  ;    LECTURER  ON   SURGERY  IN  THE 
HARVARD  MEDICAL  SCHOOL  ;     FELLOW  OF  THE  AMERICAN  SURGICAL  ASSOCIA- 
TION ;    MEMBER  OF  THE  AMERICAN  UROLOGICAL  ASSOCIATION 


Seventh  BMtion,  ICborougbl^  ■|Repise^  an&  Bnlargeb 


Wttb  33n  ITlluatrations 


PHILADELPHIA  AND  LONDON 

W.    B.   SAUNDERS    COMPANY 
1911 


m 


Copyright,  1900,  by  W.  B.  Saunders  and  Company.  Revised,  reset,  reprinted,  andrecopy- 
righted  January,  1901.    Revised,  reset,  reprinted,  and  recopyrighted  August, 
1902.  Revised,  reset,  electrotyped,  printed,  and  recopyrighted  November, 
1903.   Reprinted  April,  1904.   Revised,  reprinted,  and  recopyrighted 
June,  1905.    Reprinted  January.  1906,  and  January,  1907.    Re- 
vised, reprinted,  and  recopyrighted  November,  1907. 
Reprinted  November,  1908,  December,  1909,  and 
June,    1910.    Revised,  reprinted,  and   re- 
copyrighted April,  1911. 


Copyright,  1911,  by  W.  B.  Saunders  Company. 


PRINTED     IN     AMERICA 

PRESS     OF 

B.     SAU'NDERS     C  O  M  PA 

PHIUADEI-PHIA 


ARTHUR  TRACY  CABOT,  A.M.,  M 


PREFACE  TO  THE  SEVENTH   EDITION 


In  this  edition  my  original  purpose  has  been  constantl}^  in 
mind — the  presentation  in  concise  and  illustrated  form  of  the 
efficient  methods  of  treating  the  common  fractures  of  bone. 

This  seventh  edition  differs  chiefly  from  its  predecessors  in 
containing  those  facts  which  have  during  the  past  three  years 
been  accepted  as  important  in  the  treatment  of  bone  injuries. 

On  account  of  the  increasing  interest  in  the  operative  treat- 
ment of  fractures  I  have  introduced  a  chapter  dealing  with  this 
subject.  Many  X-rays  replace  tracings  of  types  of  fractures, 
and  there  have  been  added  to  the  legends  of  certain  X-rays  brief 
suggestions  regarding  the  treatment  of  such  injuries.  It  is  hoped 
that  the  value  of  the  illustrating  X-rays  has  been  enhanced. 

New  material  has  been  added,  particularly  in  connection  with 
the  following  subjects:  Fractures  of  the  skull;  old  fractures  of 
the  nasal  bones;  fractures  of  the  spine;  excision  of  the  shoulder- 
joint;  damage  to  the  musculospiral  nerve;  fractures  of  the  neck 
of  the  femur;  old  fractures  of  the  lower  end  of  the  tibia;  injuries 
to  the  lower  tibial  epiphysis. 

Charles  L.  Scudder. 
209  Beacon  Street,  Boston, 
April,  1911. 


PREFACE  TO  THE  FIRST  EDITION 


The  general  employment  of  anesthesia  in  the  examination 
and  the  initial  treatment  of  fractures,  especially  of  those  near 
or  involving  joints,  has  made  diagnosis  more  accurate  and  treat- 
ment more  intelligent.  The  application  of  the  Rontgen  ray  to 
the  diagnosis  of  fracture  of  bone  has  already  contributed  much 
toward  an  accurate  interpretation  of  the  physical  signs  of  frac- 
ture. This  greater  certainty  in  diagnosis  has  suggested  more 
direct  and  simpler  methods  of  treatment.  Antisepsis  has  opened 
to  operative  surgery  a  very  profitable  field  in  the  treatment  of 
fractures.  The  final  results  after  the  open  incision  of  closed 
fractures  emphasize  the  fact  that  anesthesia,  antisepsis,  and  the 
Rontgen  ray  are  making  the  knowledge  of  fractures  more  exact, 
and  their  treatment  less  complicated.  The  attention  of  the  stu- 
dent is  diverted  from  theories  and  apparatus  to  the  actual  con- 
ditions that  exist  in  the  fractured  bone,  and  he  is  encouraged  to 
determine  for  himself  how  to  meet  the  conditions  found  in  each 
individual  case  of  fracture. 

This  book  is  intended  to  serve  as  a  guide  to  the  practitioner 
and  student  in  the  treatment  of  fractures  of  bone.  In  the  follow- 
ing pages  many  of  the  details  in  the  treatment  of  fractures  are 
described.  So  far  as  possible  these  details  are  illustrated.  A 
few  very  unusual  fractures  are  omitted.  Mechanical  simplicity 
is  advocated.  An  exact  knowledge  of  anatomy  combined  with 
accurate  observation  is  recognized  as  the  proper  basis  for  the 
diagnosis  and  treatment  of  fractures.  The  expressions  "closed" 
and  "open"  fracture  are  used  in  place  of  "simple"  and  "com- 
pound" fracture.  "Closed"  and  "open"  express  definite  condi- 
tions, referring  to  the  freedom  from,  or  liability  to,  bacterial  infec- 
tion. The  old  expressions  are  misleading  despite  their  long 
usage.     Theories    of    treatment    are    not    discussed.     Types    of 


12  PREFACE 

dressings  for  special  fractures  are  described.  Many  illustrative 
clinical  cases  are  omitted  purposely. 

The  tracings  of  the  Rontgen  rays,  which  have  been  very  gen- 
erally used  to  illustrate  the  sites  and  the  displacements  of  frac- 
tures, have  been  the  subject  of  careful  study.  Each  tracing 
represents  the  combined  interpretation  of  the  plate  made  by 
skilled  observers  who  were  in  every  instance  familiar  with  the 
clinical  aspects  of  the  case.  The  writings  of  many  who  have 
contributed  their  experience  to  the  literature  of  fractures  have 
been  consulted.  Those  to  whom  I  feel  indebted  for  suggestions 
are  mentioned  in  the  section  on  Bibliography.  References  to 
literature  are  not  made  in  the  text. 

I  take  this  opportunity  to  extend  my  thanks  to  the  members 
of  the  Surgical  Staff  of  the  Massachusetts  General  Hospital  for 
their  courtesy  in  permitting  me  to  study  cases  of  fracture  of  the 
lower  extremity  in  the  wards  of  the  hospital,  and  to  Professor 
Thomas  Dwi^ht  for  the  use  of  valuable  anatomical  material.  I 
also  thank  Dr.  F.  J.  Cotton  for  an  untiring  interest  in  the  pro- 
duction of  most  of  the  drawings,  and  in  the  search  for  fracture 
literature.  The  half-tones  are  made  from  photographs  taken 
under  the  direct  superintendence  of  the  author.  Due  credit  for 
illustrations  not  original  is  given  next  the  legend. 

I  wish  to  thank  Mr.  Walter  Dodd  for  his  courtesy  and  interest 
connected  with  the  production  of  the  Rontgen-ray  plates,  and 
Dr.  H.  P.  Mosher  for  kind  assistance. 

The  chapter  on  the  Rontgen  ray  is  written  by  Dr.  E.  A.  Codman. 

Charles  L.  Scudder 


TABLE  OF  CONTENTS 


CHAPTER   I  PAGE 

Fractures  of  the  Skull 17 

Fractures  of  the  Vault 25 

Fractures  of  the  Base 28 

Treatment 39 

Later  Results  of  Injuries  to  the  Head 47 

Obstetric  Fractures 55 

CHAPTER   II 

Fractures  of  the  Nasal  Bones 56 

The  Nasal  Septum 60 

Treatment 61 

Old  Fractures  of  the  Nasal  Bones 65 

Fractures  of  the  Malar  Bone • 67 

Treatment 70 

Fractures  of  the  Superior  Maxilla 71 

Treatment 72 

Fractures  of  the  Inferior  Maxilla 74 

Treatment 77 

CHAPTER   III 

Fractures  of  the  Vertebr/E 91 

Injuries  to  the  First  Two  Cervical  Vertebree 102 

Treatment 105 

Gunshot  Fractures  of  the  Vertebrae 119 

CHAPTER   IV 

Fractures  of  the  Ribs 121 

CHAPTER   V 

Fractures  of  the  Sternum 127 

CHAPTER   VI 

Fractures  of  the  Pelvis 130 

Treatment 132 

Rupture  of  the  Urethra i35 

Rupture  of  the  Urinary  Bladder i39 

CHAPTER    VII 

Fractures  of  the  Clavicle ■  141 

Treatment  in  Adults i44 

Treatment  in  Children 150 

Operative  Treatment I53 

13 


14  TABLie   OF   CONTENTS 

CHAPTER   VIII  PAGE 

Fractures  of  the  Scapula 155 

Treatment 158 

CHAPTER  IX 

Fractures  op  the  Humerus 160 

Fractures  of  the  Upper  End  of  the  Humerus 1 60 

Diagnosis 165 

Treatment 1 78 

Fracture  of  the  Upper  End  of  the  Humerus  with  a  Dislocation  of  the 

Upper  Fragment 186 

Indications  for  and  Results  of  Excision  of  the  Shoulder- joint  for  Frac- 
ture and  Dislocation 188 

Fractures  of  the  Shaft  of  the  Humerus 196 

Fractures  of  the  Shaft  with  Little  Displacement 200 

Fractures  of  the  Shaft  with  Considerable  Displacement 209 

Fractures  of  the  Shaft  in  the  Newborn 212 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus 213 

Fractures  of  the  Elbow 227 

Diagnosis 234 

Treatment 244 

Volkmann-Leser  Contracture 266 

End  Results  in  Fractures  of  Lower  End  of  Humerus  in  Childhood.  .  .  .  272 

CHAPTER   X 

Fractures  of  the  Bones  of  the  Forearms 284 

Fractures  of  Both  Radius  and  Ulna 284 

Treatment 296 

Non-union  of  Fractures 307 

Fractures  of  the  Olecranon 311 

Treatment 316 

Colles'  Fracture 323 

Diagnosis 335 

Treatment 341 

CHAPTER    XI 

Fractures  of  the  Carpus,  Metacarpus,  and  Phalanges 355 

Fractures  of  the  Carpus 355 

Fractures  of  the  Metacarpus 361 

Fractures  of  the  Phalanges 373 

Open  Fractures  of  the  Phalanges 375 

CHAPTER    XII 

Fractures  of  the  Femur 376 

Fracture  of  the  Hip  or  Neck  of  the  Femur 376 

Treatment 387 

Fracture  of  the  Neck  of  the  Femur  in  Childhood 408 

Fracture  of  the  Shaft  of  the  Femur 410 

Treatment 413 

Subtrochanteric  Fracture  of  the  Femur 427 


TABLE   OF   CONTENTS  I5 

Fractures  of  the  Femur — Continued 

PAGE 

Supracondyloid  Fracture  of  the  Femur 420 

Ambulatory  Treatment  of  Fracture  of  the  Thigh 434 

Treatment  of  Fracture  of  Femur  in  the  Newborn 435 

Fracture  of  the  Thigh  in  Childhood ^.q 

Separation  of  the  Lower  Epiphysis  of  the  Femur 445 

Treatment .  ,^ 

450 

Traumatic  Gangrene .-_ 

Septicemia .^_ 

Malignant  Edema .^, 

Fat  Embolism .^. 

454 

CHAPTER    XIII 

Fractures  of  the  Patella . -5 

Treatment .gj 

Open  Fractures  of  the  Patella 4yi 

Operation  in  Recent  Closed  Fractures  of  the  Patella 477 

Old  Fractures  of  the  Patella 480 

CHAPTER    XIV 

Fractures  of  the  Leg .gj 

Treatment ,„. 

_                   .                     494 

Fractures  with  Little  or  No  Displacement  or  Swelling 495 

Fractures  with  Considerable  Immediate  Swelling 498 

Fractures  Difficult  to  Hold  Reduced 511 

Treatment  of  Open  Fractures  of  the  Leg 514 

Results  after  Fractures  of  the  Leg 520 

Pott's  Fracture ^21 

Treatment ^27 

Open  Pott's  Fracture -^5 

The  Operative  Treatment  of  Old  Fractures  of  the  Leg  Near  the 

Ankle c,8 

CHAPTER    XV 

Fractures  of  the  Bones  of  the  Foot 543 

Fracture  of  the  Astragalus 343 

Fracture  of  the  Os  Colds 545 

Open  Fracture  of  theAstragalus  and  Os  Calcis 551 

Fracture  of  the  Scaphoid   of  the  Tarsus.      Fracture  of  the  Metatasal 

Bones  . -  ,  j 

Fracture  of  the  Phalanges 553 

CHAPTER    XVI 

The  Operative  Treatment  of  Fractures 554 

The  Method  of  Operating  upon  the  Shafts  of  the  Long  Bones 560 

CHAPTER    XVII 

Pathological  Fractures 564 


l6  TABLE    OF   CONTENTS 

CHAPTER   XVIII  PAGE 

Anatomical  Facts  Regarding  the  Epiphyses  .  , 571 

CHAPTER  XIX 

Gunshot  Fractures  oe  Bone 585 

Treatment 592 

CHAPTER    XX 

The  Rontgen  Ray  and  Its  Relation  to  Fractures 598 

By  E.  a.  Codman,  M.D. 

CHAPTER    XXI 

The  Employment  of  Plaster-of-Paris 614 

CHAPTER   XXII 

The  Ambulatory  Treatment  of  Fractures 636 

CHAPTER  XXIII 

Notes  upon  a  Few  Common  Dislocations 644 

Dislocation  of  the  Cervical  Vertebrae 644 

Dislocation  of  the  Jaw 65 1 

Dislocation  of  the  Clavicle 655 

Dislocation  of  the  Acromioclavicular  Joint 658 

Dislocation  of  the  Shoulder 661 

Recurrent  Dislocations  of  the  Shoulder 666 

Old  Unreduced  Dislocations 666 

Unreduced  Dislocations  of  the  Shoulder 668 

Dislocation  of  the  Elbow 673 

Dislocation  of  the  Thumb 677 

Dislocation  of  the  Hip 680 

Dislocation  of  the  Patella 685 


BIBLIOGRAPHY 686 

INDEX 691 


THE 

Treatment  of  Fractures 


CHAPTER  I 
FRACTURES  OF  THE  SKULL 

It  is  unwise  to  consider  the  treatment  of  fracture  of  the  skull 
apart  from  a  more  or  less  systematic  review  of  traumatic  lesions 
of  the  brain. 

The  skull  is  the  brain's  protection.  In  cases  of  fracture  of 
the  skull  the  injury  to  the  brain  is  of  paramount  importance. 
The  immediate  damage  to  the  brain  may  be  caused  by  direct 
pressure  of  bony  fragments,  by  pressure  due  to  hemorrhage 
from  torn  vessels  within  the  skull,  by  bruising  of  the  brain 
itself,  or  by  cerebral  edema.  Great  interest  attaches  to  serious 
head-injuries,  not  only  because  the  brain  may  be  damaged, 
but  more  especially  because  the  lesions  are  often  obscured  by 
an  intact  scalp.  A  proper  determination  of  the  conditions 
existing  after  a  given  head-accident  necessitates  careful  obser- 
vation of  symptoms,  combined  with  good  judgment  in  inter- 
preting the  signs  present. 

Concussion  and  Contusion  of  the  Brain. — A  concussion 
and  a  contusion  of  the  brain  associated  with  minute  bruising 
of  brain-tissue  will  exist  after  all  serious  injuries  to  the  skull. 

The  symptoms  of  concussion  are  varied  according  to  the 
severity  of  the  injury.  Following  slight  concussion,  the  in- 
dividual is  stunned  by  the  accident;  there  is  simple  vertigo, 
possibly  mental  confusion,  lasting  but  a  short  time.  After  severe 
concussion  there  will  follow  a  momentary  loss  of  consciousness, 

2  17 


1 8  FRACTURES   OF   THE    SKULL 

or  there  may  be  unconsciousness  of  longer  duration.  Vomiting 
may  occur.  Headache  will  probably  be  present.  Following 
a  still  THore  severe  concussion,  the  patient  will  be  profoundly 
unconscious  for  a  long  period.  The  sphincters  may  be  relaxed ; 
hence  involuntary  micturition  and  defecation  will  occur  when 
the  bladder  and  rectum  become  overdistended.  Retention  of 
urine  and  feces  is  the  sign  immediately  after  the  injury.  In- 
continence is  the  evidence  of  overdistention  of  the  viscus  in 
these  cases.  The  pulse  will  become  feeble  and  slow  along  with 
the  general  systemic  depression.  The  pupils  still  react  to 
light.     The   temperature    will   be    subnormal.     It   is   impossible 


Fig.   I.— Fracture  of  skull,  middle  meningeal  hemorrhage.      Extradural  blood-clot   (after 

Helferich). 


clinically  to  distinguish  between  concussion  and  contusion  of 
the  brain.  The  pathological  differences  are  more  or  less 
artificial.  Recovery  from  the  immediate  effects  of  the  concus- 
sion of  the  brain  may  leave  the  patient  somewhat  disturbed  men- 
tally and  with  a  more  or  less  complete  memory  loss  of  events 
which  occurred  at  the  time  of  and  just  subsequent  to  the  injury 
causing  the  concussion.  There  may  also  persist  headache,  dizzi- 
ness, and  perhaps  nausea. 

These  symptoms  following  concussion  may  be  present  for  days 
or  weeks  and  will  be  a  source  of  annoyance  and  the  basis  undoubt- 
edly of  post-traumatic  neuroses. 

Laceration  of  the  Brain. — If  there  is  serious  laceration  of  the 


COMPRESSION    OF   THE    BRAIN  I9 

brain,  the  symptoms  of  concussion  may  be  present  to  a  marked 
degree,  and  will  be  characterized  by  immediate,  pronounced,  and 
long-continued  unconsciousness.  After  recovery  from  the  initial 
shock  of  the  accident  fever  will  be  present,  which  may  rise  to 
103°  or  104°  F.  Concussion  alone  is  never  associated  with 
feverishness.  Early  fever  is  a  sign  of  laceration.  Mental  irri- 
tability and  restlessness  will  mark  returning  consciousness.  If 
the  motor  areas  of  the  brain  are  involved,  signs  of  irritation 
vsall  appear — namely,  muscular  twitchings  and  spasms  accord- 
ing to  the  motor  centers  implicated. 

Compression  of  the  Brain. — According  to  physiologic  experi- 
ments invasion  of  the  intracranial  space  must  effect  three  things: 
I,  a  driving  out  of  cerebrospinal  fluid;  2,  a  compression  of  the 
easily  compressible  veins,  causing  a  venous  stasis;  3,  a  com- 
pression of  the  arterial  vessels,  causing  an  anemia  of  that  part. 

Kocher  has  divided  the  phenomena  attending  compression 
into  four  groups  dependent  upon  the  circulatory  disturbance 
reached  by  the  abnormal  intracranial  pressure: 

The  first  group  of  symptoms  correspond  to  a  mild  grade  of  com- 
pression, the  cerebrospinal  fluid  is  driven  out.  Moderate  venous 
stasis  results.  The  symptoms  are  moderate,  a  Httle  headache  is 
about  all  that  is  noticed. 

The  second  group  of  symptoms  correspond  to  a  greater  venous 
stasis.  Less  blood  flows  to  a  part.  Headache,  vertigo,  rest- 
lessness, excitement,  and  deHrium  may  exist.  The  face  will  be 
slightly  cyanotic.  If  the  venous  stasis  is  at  the  medulla  then  a 
slowing  of  the  pulse  will  be  noticed. 

The  third  group  of  symptoms  correspond  to  the  anemia  of  the 
brain.  The  high-tension  pulse  is  noticed  as  the  compensatorv 
vasomotor  mechanism  acts. 

The  pulse  is  slow  in  rate,  optic  disk  choked,  facial  cyanosis 
marked,  respiration  is  stertorous. 

The  fourth  group)  of  symptoms  corresponds  to  the  failure  of  the 
arterial  compensation,  the  action  of  the  heart  and  the  lungs  be- 
comes irregular,  the  pupils  dilate,  the  pulse  becomes  rapid,  coma 
increases,  and  death  occurs. 

vSlight  hemorrhages  do  not  cause  symptoms  of  compression ; 
neither  clcj  slight  depressions  of  the  cranial  bones.     Before  symp- 


20  FRACTURES    OF   THE)    SKUI.L 

toms  of  compression  appear,  the  cranial  contents  must  be  impinged 
upon  to  a  very  considerable  extent.  //  the  compression  is  sudden 
and  limited,  there  is  an  irritation  of  the  parts  involved,  which  is 
manifested  by  restlessness  and  delirium  and  by  twitching  of  certain 
groups  of  muscles;  the  pulse  is  hard  and  slow.  //  the  compression 
is  gradual,  whether  it  be  localized  or  diffused,  the  brain  accommo- 
dates itself  for  some  time  to  the  new  conditions;  the  appear- 
ance of  the  symptoms  of  local  pressure  is  delayed,  although 
they  may  be  relatively  sudden  in  their  onset.  Following  the 
muscular  spasms  and  twitchings  due  to  the  sudden  onset  of 
pressure  there  may  appear  symptoms  of  paresis  and  paralysis. 
Loss  of  power  in  the  face  or  arm  or  leg  indicates  a  lesion  about 
the  fissure  of  Rolando,  upon  the  opposite  side.  Loss  of  power, 
for  example,  in  the  right  arm  and  right  leg  indicates  that  the 
brain  lesion  is  about  the  fissure  of  Rolando  upon  the  left  side 
of  the  brain.  If  there  is  pressure  upon  the  third  nerve  at  the 
base  of  the  skull,  dilatation  of  the  pupil  upon  the  side  opposite 
to  the  pressure  will  be  noticed.  This  pupil  will  not  react  to 
light.  As  the  pressure  of  the  hemorrhage  increases,  the  symp- 
toms will  again  become  more  general;  convulsive  movements 
of  the  limbs  and  body  appear,  and  the  drowsiness  or  stupor 
increases  to  profound  unconsciousness;  the  pulse  becomes  rapid 
and  small;  and  the  respiration  frequent,  shallow,  and  sighing, 
or  it  passes  into  stertor  and  Cheyne-Stokes'  breathing  as  the 
condition  becomes  immediately  grave;  the  temperature  rises 
high.  Focal  symptoms  may  exist  from  pressure  by  bone  or 
blood-clot,  apart  from  loss  of  consciousness. 

Extradural  Hemorrhage — Middle  Meningeal  Hemorrhage 
(see  Figs,  i,  2,  3,  4;  also  Case  No.  i  at  end  of  chapter). — A  most 
important  symptom  of  traumatic  intracranial  hemorrhage  is  the 
interval  of  consciousness  that  exists  from  the  time  of  the  injury  to 
the  onset  of  unconsciousness.  This  period  of  consciousness  may 
be  preceded  by  the  temporary  or  prolonged  unconsciousness  of 
concussion.  Unconsciousness  in  cases  of  intracranial  hemorrhage 
is  due  to  an  increase  of  the  intracranial  pressure  caused  by  the 
presence  of  free  blood.  An  interval  of  consciousness  exists  in 
these  instances  in  from  one-half  to  two-thirds  of  all  cases.  In 
the   cases   of  hemorrhage   which   occur   without   an   interval   of 


EXTRADURAL  HEMORRHAGE 


21 


consciousness  (unconsciousness  coming  on  immediately  upon  the 
receipt  of  the  injury)  it  must  be  that  the  injury  is  so  severe  that 
the  unconsciousness  caused  by  the  concussion  and  laceration  of 
the  brain  is  continuous  with  the  unconsciousness  from  hemor- 
rhage.    The  unconsciousness  of  concussion  is  continued  over  into 


Fig.  2. — Fracture  of  skull  with  middle 
meningeal  hemorrhage.  Compression  of 
brain  by  blood  alone.    Extradural  hemorrhage. 


Fig.  3. — Fracture  of  skull  with  de- 
pressed fragments  Compression  of  brain 
by  bone  and  blood. 


the  coma  of  compression.  The  duration  of  the  interval  of  con- 
sciousness may  vary  within  very  wide  limits;  it  may  be  a  few 
moments,  it  may  be  three  months. 

In  cases  of  intracranial  hemorrhage  the  first  or  minor  symp- 
toms of  compression  are  found  in  association  with  varying  degrees 
of  intracranial  venous  stasis,  the  major  symptoms  in  association 
with  an  approaching  capillary  anemia  of  the  medulla  (Gushing, 
Cannon). 

The  sources  of  intracranial  hemorrhage,  whether  from  the 
middle  meningeal  artery  or  its  branches,  from  the  middle  cerebral 
arteries,  from  the  veins  of  the  pia  mater,  from  the  sinuses  of  the 
brain,  or  from  lacerated  brain -tissue,  can  not  be  easily  differen- 
tiated short  of  operative  procedure.      The  most  common  source 


22 


FRACTURES   OF   THE    SKULL 


of  intracranial  hemorrhage  is    the  torn  anterior  branch  of    the 
middle    meningeal    artery;    the  next    most  frequent    source    of 


Fig.  4. — Photograph  of  calvarium  with  tliira  rcilccterl,  showing  extradural  clot  grooved  by  the 
meningeal  artery,  which  had  been  torn  by  the  linear  assure.  1-rom  a  fatal  case  of  meridional  fracture. 
Arrows  indicate  line  of  fracture  (Gushing). 

hemorrhage  is  the  posterior  branch  of  the  same  artery,     There 
is  one  condition  which  is  not  to  be  overlooked  in  connection  with 


^tf***  •»  ♦•'*^'^^^«N*(M 


Fig.  5. — Splintering  of  inner  table ;  cross-sections  ;   diagrammatic  :  a,  Usual  form  of  punctate  frac- 
ture ;   6,  shows  that  a  linear  fracture  may  be  much  more  extensive  internally  than  externally. 


the  question  of  hemorrhage — namely,  the  period  of  semiconscious- 
ness which  sometimes  follows   concussion   and    laceration,   and 


Fig.  6. — Case  of  compound  depressed  fracture  of  the  frontal  bone.     Note  extent  of  depression. 
Recovery  (Harrington). 


j,-,g_  y_ — Normal  skull.     Note  relations  of  fuciul  bones  in  connection  with  fig.  15. 

23 


24  FRACTURES   OF    THE;  SKULL 

gives  rise  to  the  suspicion  of  some  more  serious  gross  lesion.  To 
illustrate:  A  young  girl  received  a  severe  blow  upon  the  head. 
A  true  period  of  unconsciousness  followed.  There  were  no  external 
evidences  of  hemorrhage.  Convulsive  movements,  deviation  of 
the  eyes,  and  disturbance  of  the  pupils  were  absent.  The  breath- 
ing was  regular  and  of  normal  character.  Notwithstanding  the 
absence  of  other  untoward  symptoms,  complete  consciousness 
did  not  return  for  a  number  of  days  or  even  of  weeks.  In  such 
a  case,  after  a  number  of  days  the  question  naturally  presents 
itself.  Have  we  not  to  do  with  a  hemorrhage,  and  should  not 
trephining  be  considered?  The  absence  of  all  symptoms  except- 
ing the  unconsciousness  should  lead  to  the  suspicion  that  we  have 
to  do  with  a  mental  state  rather  than  with  a  gross  lesion.  Hys- 
teroid  semiconsciousness  (Walton)  supervening  upon  a  blow  is 
not  to  be  mistaken  for  the  deepening  unconsciousness  which 
indicates  hemorrhage. 

Subarachnoid  Serous  Exudation  (Cerebral  Edema). — A  se- 
vere blow  upon  the  head,  with  or  without  fracture  of  the  skull, 
may  result  in  a  local  bruising  and  in  congestion  and  swelling 
of  the  brain-tissue,  with  serous  exudation  into  the  subarachnoid 
space,  either  with  or  without  edema  of  the  brain-substance. 
If  this  accumulation  of  fluid  occurs  over  the  motor  area,  localized 
symptoms,  as  if  of  hemorrhage,  may  appear.  The  lesion  is 
usually  self-limited,  the  resulting  paralysis  disappearing  in  the 
course  of  a  few  days.  The  careful  observation  of  the  onset 
and  sequence  of  the  signs  of  compression  is  of  the  very  greatest 
importance,  for  it  is  by  a  proper  interpretation  of  these  localizing 
symptoms  that  the  surgeon  is  led  to  operate,  and  then  is  enabled 
to  remove  the  compressing  blood-clot  or  the  depressed  fragment 
of  bone. 

THE  FRACTURE  OF  THE  SKULL 
Whether  the  wound  of  the  bone  is  compound  or  simple,  open 
or  closed,  is  of  comparatively  little  importance,  because  of  the 
very  general  recognition  and  employment  of  aseptic  and  anti- 
septic methods.  A  knowledge  of  the  nature  of  the  fracture 
will  help  in  determining  the  injury  to  the  brain.  If  there  is  a 
perforating   fracture,    or   if   the   fragments   are   comminuted   or 


THE  FRACTURE  OF  THE  SKULL  25 

depressed,  then  it  is  highly  probable  that  a  tremendous  or  sharply 
localized  force  has  been  exerted  upon  the  bone,  and  that,  in  con- 
sequence, the  injury  to  the  underlying  brain  is  serious.  It  is 
a  generally  accepted  fact  that  the  skull  may  be  simply  contused 
and  the  great  lateral  sinus  ruptured,  with  resulting  fatal  hemor- 
rhage. It  is  likewise  true  that  the  bone  may  present  but  a  fissure, 
but  if  that  fissure  crosses  the  middle  meningeal  artery,  or  any  of  its 
branches,  they  may  be  torn  across  (see  Figs,  i,  2,  and  4)  and  the 
consequent  hemorrhage  and  associated  intracranial  pressure  will 
prove  disastrous  unless  checked  by  surgical  interference.  On 
the  other  hand,  the  bone  in  the  frontal  region  may  be  greatly 
damaged,  literally  crushed,  and  yet  no  grave  symptoms  arise 
(see  Fig.  6).  The  extent  of  the  bone-lesion  is,  however,  of  the 
greatest  importance. 

Fracture  of  the  Vault  of  the  Skull  (see  Fig.  8). — Fractures 
of  the  vault  of  the  skull  without  involvement  of  the  base  are 
much  more  unusual  than  is  generally  supposed.  More  than 
two-thirds  of  all  fractures  of  the  vault  are  associated  with  frac- 
ture of  the  base  of  the  skull  (see  Figs.  8,  9,  10,  11)  Evidences 
of  fracture  of  the  vault  are  determined  by  sight  and  touch.  A 
wound  in  the  scalp  may  disclose  the  fractured  bone.  Whether 
this  is  a  mere  fissure  or  a  single  or  a  comminuted  fracture,  whether 
depressed  or  not  below  the  general  surface  of  the  normal  skull, 
can  be  determined  only  by  careful  inspection.  A  fissure  of  the 
bone  may  be  difficult  of  recognition.  It  must  be  remembered 
in  this  connection  that  blood  can  not  be  wiped  from  a  fissure, 
whereas  from  the  normal  suture  lines  it  can  readily  be  wiped  away. 
Blood  may  be  seen  escaping  through  a  fissure.  Torn  periosteum 
must  not  be  confused  with  a  fissure  of  the  bone. 

It  is  not  an  uncommon  experience  for  the  surgeon  to  be  called 
to  an  individual  who  is  unconscious  following  a  blow  on  the  head. 
A  swelling  is  evident  on  the  top  or  side  of  the  head.  Palpation 
of  this  swelling  may  mislead  one  into  thinking  that  a  depressed 
fracture  of  the  skull  is  present  when  only  a  hematoma  of  the 
scalp  exists. 

A  hematoma  of  the  scalp  may  suggest  a  depressed  fracture  of 
the  skull  (see  Fig.  12).  The  center  of  the  blood-tumor  is  soft; 
the  edges  are  edematous  and  hard.    If  the  finger  be  pressed  firmly 


26 


FRACTURES   OF   THE    SKUI^E 


Fig.   8. — Depressed  fracture  of  frontal  bone  from  outside,  showing  depression  of  fragments 
(Warren  Museum,  specimen  7951). 


Fig.  9. — Same  as  figure  8;  inner  surface  from  within  ;  shows  excess  of  bone-formation. 


THE   FRACTURE   OF   THE    SKULL 


27 


Fig.  lo. 


Depressed   fracture  of  right   frontal   bone :   a,  Point  toward  vertex  ;   6,  anterior 
corner;  c,  lower  outer  end  (Warren  Museum,  4721). 


Fig.  II.— Same  from  within  ;  letters  as  in  figure  10.    Fracture  shows  depression  without  much 
new  bone-formation  (Warren  Museum,  4721). 


28 


FRACTURES   OF  THE   SKULL 


into  the  soft  center,  an  intact  skull  generally  will  be  felt.  The 
uniform  edge  of  a  hematoma  is  unlike  the  irregular  jagged  edge 
of  a  fracture.  It  is  sometimes  impossible  to  distinguish  between 
a  hematoma  and  a  fracture  of  the  skull.  The  symptoms  of 
general  disturbance  are  usually  more  marked  and  prolonged  in 
the  case  of  a  fracture  of  the  skull  than  when  only  a  hematoma 
is  present. 


Fig.  12. — No  fracture  of  skull.     Hematoma  of  scalp,  the  soft  center  and  firm  edge  of  which 

often  simulate  fracture. 


Fracture  of  the  Base  of  the  Skull  (see  Fig.  i8). — It  is  not 
uncommon  to  discover  that  what  in  the  vault  appears  to  be 
a  simple  fissure  continues  down  to  and  involves  the  base  of 
the  skull.  Fractures  of  the  base  of  the  skull  are  usually  re- 
garded, and  rightly  so,  as  more  serious  than  fractures  of  the 
vault.  A  greater  trauma  being  necessary  to  cause  the  fracture, 
the  cerebral  disturbance  is  more  pronounced  and  vital  parts  are 
endangered.  These  fractures  of  the  base  often  open  into  cavities 
which  it  is  impossible  to  keep  surgically  clean — namely,  the 
cavities  of  the  nasopharynx  and  the  ear.  The  danger  of  septic 
infection,  therefore,  in  such  fractures  is  very  great.  About 
eighty-five  per  cent,  of  basic  fractures  originate  in  the  vault — 
i.  e.,  are  caused  by  an  extension  of  a  linear  fracture  of  the  vault 


fracture;  of  the;  base;  of  the;  skull 


29 


to  the  base.  A  few  basic  fractures  are  due  to  forces  acting  from 
below  and  thus  causing  a  penetration  of  the  base  of  the  skull  by 
other  bones.   The  facial  bones  may  be  forced  up  into  the  anterior 


Fig.   13. — Punctate  fracture  entering  posterior  fossa.     From  the  punctate  depression  a  line 
of  fracture  extends  downward  and  backward  (Warren  Museum,  specimen  965). 

fossa  (Figs.  14,  15).  The  articular  process  of  the  inferior  maxil- 
lary bone  may  be  pushed  up  through  the  glenoid  fossa  of  the  tem- 
poral bone  (see  Fig.  i6)  into  the  middle  fossa  by  a  blow  upon  the 


Fig-   14. — Anterior  view  of  Fig.  15  ;  note  nasal  bone. 

chin,  particularly  if  the  jaw  is  relaxed.  The  vertebral  column 
may  be  forced  up  into  the  posterior  fossa  through  a  fracture  of 
the  occiput. 


30  FRACTURES   OF    THE    SKULIv 

Symptoms  of  Fracture  of  the  Base. — Hemorrhage  may  take  place 
from  the  ear,  from  the  nose,  from  the  mouth,  or  be  noticed  under 
the  conjunctivae.  Occasionally  blood  is  seen  in  all  four  situations. 
Hemorrhage  may  occur  beneath  the  pharyngeal  mucous  membrane. 
Escape  of  cerebrospinal  fluid  from  the  ear  and  nose  may  be  noticed. 
Brain-tissue  sometimes  escapes  from  the  skull  and  is  seen  lying 
in  the  external  auditory  meatus  or  near  a  wound  which  commu- 
nicates with  the  fracture  of  the  skull.     Injuries  may  occur  to  the 


Fig.  IS-  Fracture  of  base  of  skull  ;  impaclion  of  nasal  and  part  of  ethmoid  bones,  which  pro- 
ject into  the  interior  of  the  cranium.  Male,  aged  twenty-eight  ;  diagnosis,  fracture  of  nose.  Died 
of  meningitis  (after  Helferich). 

third,  fifth,  seventh,  and  eighth  nerves.  Associated  with  these 
local  signs  may  be  the  general  signs  of  concussion  or  laceration  of 
the  brain. 

The  behavior  of  the  pupils  is  of  importance.  Lovett  and  Munro 
find  that  the  pupils  failed  to  react  in  thirty-nine  out  of  fifty-three 
fatal  cases  of  basal  fracture  in  which  they  were  recorded.  The 
pupils  failed  to  react  in  only  one  of  twelve  cases  with  recovery 
after  basal  fracture.  Nichols  finds  that  in  fifty-four  cases  of  head 
injury  with  non-reacting  pupils,  forty-seven  died,  and  that  in  the 
twenty-four  cases  diagnosticated  as  basal  fracture,  all  were  fatal. 
This  behavior  of  the  pupil  is  very  properly  to  be  regarded  as  a 
sign    of   importance    in    studying   these    cases. 

Injuries  of  Cranial  Nerves  following  Fracture  of  the  Base  of  the 
Skull. — The  order  of  frequency  of  injury  is  as  follows:  The  facial 
nerve  is  most  commonly  injured,  then  the  sixth  or  abducens,  the 
auditory  or  eighth,  the  third  nerve,  the  optic  nerve.  If,  after  a 
year,  the  facial  paralysis  does  not  improve,  it  is  wise  to  consider 
nerve  anastomosis — i.  e.,  the  hypoglossal  or  the  spinal  accessory 
with  the  peripheral  facial. 


SYMPTOMS  OF    FRACTURE   OF    THE)    BASE  31 

Anterior  Fossa. — If  the  orbital  plate  of  the  frontal  bone  is  broken, 
blood  will  gravitate  into  the  orbit ;  ecchymosis  of  the  lids  and  sub- 
conjunctival   hemorrhage    will    appear.     There   may   be    greater 


Fig.  16. — Showing  thinness  of  the  roof  of  the  glenoid  fossa,  which  is  occasionally  b:oken  by  the 
condyloid  process  of  the  inferior  maxilla  when  a  blow  is  received  on  the  jaw.  Arrow  points  to  thin 
shell  of  bone  between  dura  and  joint  below. 

tension  of  the  eyeball  upon  the  affected  side,  detected  by  pal- 
pating the  globe  through  the  closed  lid.  Subconjunctival  hem- 
orrhage may  appear  from  a  fracture  of  the  malar  (outer  wall  of 
the  orbit)  or  superior  maxillary  bones.  Subconjunctival  hem- 
orrhage is  not,  therefore,  an  infallible  sign  of  fracture  of  the  base 
of  the  skull. 

If  the  cribriform  plate  of  the  ethmoid  is  fractured,  hemorrhage 
from  the  nose  will  occur.  Impairment  of  the  sense  of  smell  may 
exist  if  the  olfactory  nerves  become  involved  in  the  fracture. 
Blood  may  trickle  from  a  fracture  of  the  base  into  the  pharynx, 
be  swallowed,  and  later  vomited.  Epistaxis,  of  course,  may  be 
due  to  a  blow  upon  the  face  without  fracture  of  the  base.  If  in- 
spection discloses  a  broken  nose  or  ecchymosis  of  the  face  or  the 
skin  of  the  forehead,  it  is  very  probable  that  the  minor  accident 
has  occurred. 

Middle  Fossa. — Most  fractures  of  the  base  involve  the  middle 
fossa.  If  the  petrous  portion  of  the  temporal  bone  is  fractured,  sev- 
eral important  signs  are  present.  If  the  tympanum  is  torn,  hem- 
orrhage from  the  external  auditory  meatus  is  sure  to  follow.  If 
this  hemorrhage  is  continuous,  it  is  significant ;  if  it  is  trifling  and 
temporary,  it  is  probably  unimportant  and  may  be  local.  Cerebral 
tissue  may  escape  from  the  nose,  thus  estabhshing  the  seat  of  the 
lesion.     Cerebrospinal   fluid   may   likewise   escape  from  the   ear. 


32  FRACTURES  OF  THE   SKUI.E 

Cerebral  tissue  may  also  appear  at  the  external  auditory  meatus. 
Any  of  these  signs  is  conclusive  evidence  that  the  base  of  the  skull 
is  fractured  and  that  there  is  a  lesion  of  the  brain.  Lesions  of  the 
facial  (seventh)  and  auditory  (eighth)  nerves  lying  within  the 
bones  occur.  Lesions  are  likewise  reported  of  the  fifth  nerve, 
because  of  its  lying  upon  the  fractured  petrous  portion  of  the 
temporal  bone.  Subconjunctival  hemorrhage  may  appear,  owing 
to  the  blood  working  its  way  forward  through  the  sphenoidal 
fissure  and  the  optic  foramen.  A  primary  profuse  watery  dis- 
charge from  the  nose  or  the  ear  is  probably  cerebrospinal  fluid.  A 
watery  discharge  appearing  late  after  such  an  injury  is  likely  to 
be  serum  from  a  blood-clot.  The  optic  nerve  may  be  involved 
in  the  injury,  with  resulting  blindness. 

About  37  per  cent,  of  the  fatal  cases  of  fracture  of  the  base  of 
the  skull  die  within  six  hours  or  less. 

About  56  per  cent,  of  the  fatal  cases  of  fracture  of  the  base  of 
the  skull  die  within  twelve  hours. 

The  mortality  of  this  group  of  cases  can  probably  never  be 
materially  reduced.     They  are  primarily  fatal  cases. 

Posterior  Fossa{V\gs.  17,  18). — If  the  posterior  fossa  is  involved 
in  the  fracture,  there  may  be  hemorrhage  into  the  pharynx. 
Fracture  of  the  base  which  opens  the  pharyngeal  mucous  mem- 
brane is  occasioned  by  tremendous  trauma.  The  pituitary  fossa 
is  fractured  in  such  cases.  The  hemorrhage  may  be  very  con- 
siderable. The  mortality  of  this  form  of  fracture  of  the  base  is 
very  high.  Ecchymosis  under  the  pharyngeal  mucous  membrane 
may  be  present  without  actual  rupture  of  the  mucous  membrane. 
A  fulness  may  be  detected  by  palpation  in  the  posterior  wall  of 
the  pharynx,  if  the  hemorrhage  there  is  considerable.  Ecchy- 
mosis just  in  front  of  the  mastoid  process,  or  a  hematoma  and 
puffy  swelling  over  the  seat  of  the  fracture,  may  determine  its 
location. 

Unconsciousness  Resulting  from  Other  than  Surgical 
Causes. — There  are  certain  conditions  associated  with  loss 
of  consciousness  and  delirium  which  must  be  differentiated 
from  traumatic  intracranial  lesions.  These  conditions  are  (a) 
the    coma    from  opium-poisoning  ;    (6)    the  unconsciousness    in 


UNCONSCIOUSNESS 


33 


uremia;  (c)  the  loss  of  consciousness  from  apoplexy;  {d)  alco- 
holic coma;  and  {e)  hemorrhagic  internal  pachymeningitis. 

Coma  from  Opium-poisoning:  The  patient  can  be  aroused 
unless  the  poisoning  is  extremely  profound,  and  can  be  made 
to  understand,  and  will  even  reply  to  an  inquiry.     The  face 


Fig.  17- — The  three  fossae  of  the  base  of  the  skull  viewed  from  above. 


at  first  is  pale,  later  it  is  flushed  and  swollen.  The  skin  is  warm 
and  moist.  The  respiration  is  slow.  The  temperature  is  sub- 
normal. The  pulse  is  slow  and  full.  The  pupils  are  strongly, 
immovably,  and  symmetrically  contracted.  The  reflexes  may 
be  absent. 

The  Unconsciousness  in  Uremia :  The  patient  can  not  be  aroused. 
The   face   is  white,   edematous,    and   puffy.     The   breath  has  a 
sweetish  odor.     The  respiration  is  frequent  and  irregular.     The 
3 


34 


FRACTURES    OF    THE    SKULL 


temperature   is  normal.     The  pulse   is   rapid.     The    pupils    are 
dilated  and  sluggish.     The  urine  usually  contains  albumin. 
The  Unconsciousness  from  Apoplexy  :  The  patient  can  not  be 


Anterior  branch 
of  middle  men- 
ingeal artery 


Gasserian 
ganglion 

Posterior  branch 
of  middle  men- 
ingeal artery 
Superior 
petrosal  siaus 


Sigmoid  sinus 


Hypoglossal  nerve 
Lateral  sinus 


Olfactory  nerve 


Optic  nerve 
Intemalcarotid 
artery 


Facial  nerve 
Auditory  nerve 
Vagus  nerve 
Glossopharyn- 

gea.  nerve 
Spinal  acces- 
sory nerve 


Fig.  iS. — View  of  base  of  skull,  showing  relation  of  cranial  nerves,  carotid  and  middle  meningeal 
arteries,  and  sinuses  to  the  fossK.  This  illustration  shows  on  the  right  side  of  the  skull  the  most  fre- 
quent lines  of  fracture  at  the  base  of  the  skull  (Eisendrath). 


aroused.  The  respiration  is  slow,  irregular,  and  stertorous. 
The  temperature  is  subnormal  at  first;  if  a  fatal  termination 
is  probable,  the  temperature  is  high.  The  pupils  are  dilated. 
Unilateral  paralysis  of  the  face  and  the  extremities  usually 
is    present.     The   affected    extremities   are   warmer   than   those 


UNCONSCIOUSNESS  35 

of  the  other  side.  The  Hmbs  may  be  relaxed,  but  in  watching 
the  patient  carefully  evidences  of  hemiplegia  will  appear.  The 
history  of  previous  hemorrhages  may  be  discovered  pointing 
to  hemorrhagic  internal  pachymeningitis. 

Alcoholic  Coma:  The  patient  can  be  aroused  by  pressure 
upon  the  supra-orbital  nerves — sometimes,  however,  with  great 
difficulty.  The  breath  may  be  alcoholic.  The  face  is  flushed. 
The  respiration  is  regular.  The  pulse  is  rapid.  The  tempera- 
ture is  normal  or  low.  The  pupils  are  normal.  There  is  an 
absence  of  the  positive  signs  of  a  cerebral  lesion.  The  tempera- 
ture in  cerebral  laceration  is  elevated.  Alcoholic  delirium  will 
present  an  elevated  temperature,  but  along  with  the  elevated 
temperature  of  a  lacerated  brain  there  will  be  symptoms  char- 
acteristic of  a  damaged  brain. 

Hemorrhagic  Internal  Pachymeningitis:  The  occurrence  of 
apoplectic  seizures  during  the  course  of  this  disease  makes  it 
important  that  it  be  recognized  in  connection  with  the  distinctly 
traumatic  hemorrhages  under  consideration.  The  character- 
istic course  shows  an  acute  diffused  affection  of  the  brain,  usually 
in  an  elderly  man  and  with  severe  symptoms.  An  acute  attack 
is  followed  by  a  fair  recovery  and  by  intervals  of  comparative 
health.  During  these  intervals  of  comparative  health  the  pa- 
tient has  some  headache,  slight  diminution  of  intelligence,  im- 
pairment of  memory,  drowsiness,  partial  paralysis  of  the  limbs 
(usually  unilateral),  disturbances  of  speech,  and  sudden  mental 
excitement  without  cause  mixed  with  symptoms  of  paralytic 
dementia.  Evidences  of  a  sudden  and  increasing  compression 
are  headache,  drowsiness,  loss  of  consciousness,  some  fever,  a 
pulse  of  compression,  and  sometimes  initial  symptoms  of  ir- 
ritation. The  diagnosis  is  assisted  by  the  etiology  and  history 
of  the  case.  In  middle  meningeal  hemorrhage  a  blow  is  neces- 
sary to  cause  alarming  symptoms,  whereas  in  hemorrhagic 
pachymeningitis  a  very  trivial  injury  or  none  at  all  is  common. 
The  longer  duration  of  the  symptoms  would  help  to  decide  against 
middle  meningeal  hemorrhage.  There  is  often  a  rigidity  of 
the  limbs  in  hemorrhagic  pachymeningitis  which  is  absent  in 
middle  meningeal  hemorrhage  cases. 


3^  fracture;s  of  the  skull 

When  called  upon  to  see  a  case  of  head-injury,  it  must  be 
remembered  that  the  lesion  can  not  always  be  determined  by 
the  first  observation  of  the  patient.  It  is  absolutely  necessary 
that  there  be,  upon  the  part  of  the  physician,  a  clear  under- 
standing of  the  method  of  onset  and  the  sequence  of  symptoms 
from  the  time  of  the  receipt  of  the  injury.  Isolated  signs  are  of 
less  importance  than  relative  symptoms. 

Examination  of  the  Patient. — The  following  comprehen- 
sive method  of  examining  an  individual  who  has  received  a 
severe  injury  to  the  head  should  be  carefully  followed,  bearing 
in  mind  always  the  possible  cranial  and  intracranial  lesions, 
and  remembering  that  a  fracture  of  the  skull  as  such  is  of 
secondary  importance,  that  an  injury  to  the  intracranial  vessels 
is  serious,  and  that  a  lesion  of  the  brain  itself  is  most  important. 

If  with  brain  symptoms  there  is  no  visible  injury  to  the  skull, 
the  head  should  be  shaved  to  facilitate  careful  examination. 
Acute  localized  pain  suggests  the  seat  of  fracture. 

When  was  the  Accident  ? — How  much  time  has  elapsed  between 
the   accident    and    the    first    accurate    observation? 

What  was  the  Accident  9 — Was  it  a  fall  or  a  blow? 

What  is  the  Age  of  the  Patient  9 — Are  the  arteries  atheromatous, 
and  therefore  easily  ruptured  by  trivial  injury?  Is  it  the  skull 
of  a  child — which  is  softer  and  less  brittle  than  that  of  an 
adult? 

What  was  the  Condition  of  Health  Previous  to  the  Accident  ? — 
Was  it  poor — suggestive  of  kidney-disease  and  uremia?  Was 
the  man  alcoholic,  or  is  the  present  condition  masked  by  alcohol 
taken  subsequent  to  the  accident? 

The  General  Condition  of  the  Patient. — If  unconsciousness  is 
present,  was  its  onset  immediate,  or  was  there  a  lucid  interval 
after  the  accident?  Has  the  unconsciousness  been  continuous, 
and  is  it  deepening  or  lessening? 

What  are  the  Evidences  of  Shock  Present  ? — What  is  the  condition 
of  the  pulse,  of  the  respiration,  of  the  skin?  What  is  the  tem- 
perature taken  in  the  rectum?  Has  vomiting  occurred?  Have 
there  been  involuntary  dejections?  Has  there  been  involuntary 
micturition? 


EXAMINATION    OF    THE    PATIENT  37 

The  Local  Condition. — The  wound  of  the  scalp,  skull,  or  brain 
may  be  evident.  If  hemorrhage  is  present,  what  is  its  source? 
Is  it  from  the  nose,  the  mouth,  the  ear,  or  into  the  orbit?  When 
did  the  hemorrhage  occur?  What  was  its  amount?  Was  it 
continuous  or  not?  Palpation  should  be  made  of  the  skull, 
the  neck,  the  face,  the  spine,  the  jaw,  and  the  temporo-maxil- 
lary  joint. 

Are  Any  Localizing  Signs  Present  ? — What  is  the  condition 
of  the  pupils,  and  of  the  muscles  of  the  face,  the  arms,  and  the 
legs?  What  is  the  condition  of  the  reflexes  and  of  the  respira- 
tion?    Does  hemiplegia,  either  partial  or  complete,  exist? 

Finally,  the  whole  body  should  be  examined  systematically 
for  any  other  injuries  than  those  to  the  head  and  to  the  nervous 
system.  Associated  injuries,  if  discovered,  may  assist  in  in- 
terpreting the  nature  of  the  cerebral  injury. 

A  diagnosis  must  be  based  upon  all  available  evidence.  One 
will  have  to  consider  concussion  and  laceration  of  the  brain 
and  pressure  upon  the  brain  by  serum,  blood,  and  bone. 

In  contusion  there  is  not  likely  to  be  a  great  subarachnoid  extrav- 
asation, but  in  cases  associated  with  more  or  less  laceration  of 
cortical  brain  tissue  blood  will  be  present  in  the  subarachnoid 
space.  A  lumbar  puncture  should  be  made  for  purposes  of  diag- 
nosis in  all  doubtful  cases.  If,  as  Gushing  has  pointed  out,  a 
patient  has  a  high  blood-pressure  and  is  in  shock  of  the  third  stage 
of  Kocher,  it  mav  be  dangerous  to  draw  fluid  off  by  lumbar  punc- 
ture; death  is  likely  to  occur.  Subdural  hemorrhage  will  be  de- 
tected by  lumbar  puncture. 

The  pressure  under  which  the  rose-colored  cerebrospinal  fluid 
comes  from  the  needle  will  be  a  rough  visual  index  of  the  intra- 
cranial pressure. 

The  important  signs  to  be  studied  in  diagnosis  are  the  different 
aspects  of  unconsciousness;  the  relative  and  actual  conditions 
of  the  respiration,  pulse,  and  temperature;  the  occurrence  of 
hemorrhage;  restlessness  and  muscular  twitching;  localizing 
signs  of  pressure.  If  the  symptoms  are  not  positive,  if  there  is 
no  history  of  trauma,  if  the  history  of  a  lucid  interval  preceding 
unconsciousness  is  doubtful,  or  if  there  is  no  history  at  all,  then 
the  diagnosis  will  be  most  difficult.     It  is  when  positive  symp- 


38  FRACTURES   OF   THE    SKULE 

toms  are  absent  that  one  must  particularly  consider  those  con- 
ditions already  mentioned  in  which  coma  is  a  prominent  sign — 
namely,  opium-poisoning,  uremia,  apoplexy,  alcoholism. 

General  Observations. — An  unconscious  man  having  a 
scalp  wound  and  a  breath  smelling  of  liquor  is  not,  necessarily, 
drunk.  He  may  have  an  intracranial  lesion.  Multiple  lesions 
may  be  present  in  any  case.  A  diffuse  lesion  may  obscure  a 
localized  lesion.  Not  only  must  the  location  of  a  lesion  be  deter- 
mined, but  also  its  character,  if  possible.  The  symptoms  must 
be  recorded  in  the  order  of  their  appearance.  The  manner 
in  which  various  symptoms  develop  should  be  noted.  The 
danger  to  the  brain  is  greatest  in  perforating  and  sharply  de- 
pressed fractures.  Slight  fissures  may  be  associated  with  ex- 
tensive hemorrhages.  Great  comminution  of  bone  may  be 
devoid  of  much  danger.  In  cases  of  compound  fracture  fis- 
sures apparently  closed  afford  the  possibility  of  cerebral  and 
meningeal  infection  through  dirt  having  entered  when  the  fis- 
sure was  open. 

Unconsciousness  and  a  superficial  head-lesion,  with  or  without 
fracture  of  the  skull,  must  make  one  suspicious  of  an  intracranial 
lesion.  An  immediate  loss  of  consciousness  indicates  a  diffused 
contusion  or  concussion  of  the  brain.  If  the  primary  unconscious- 
ness is  prolonged,  probably  hemorrhage  has  occurred,  or  possibly 
a  serous  exudation  with  its  resulting  pressure  upon  the  brain. 

If  there  is  a  conscious  interval  preceding  the  unconsciousness, 
a  hemorrhage  is  probable.  Momentary  unconsciousness  means 
concussion.  Recurring  unconscious  periods  indicate  hemorrhage. 
Deepening  unconsciousness  indicates  increasing  intracranial  pres- 
sure— probably  hemorrhage.  Immediate  profound  unconscious- 
ness suggests  hemorrhage  from  the  rupture  of  an  intracranial 
sinus. 

The  temperature  in  all  intracranial  lesions  is  usually  slightly 
above  normal.  Intoxication  and  shock  depress  the  tempera- 
ture. In  a  small  intracranial  hemorrhage  there  will  be  a  slight 
rise  of  temperature,  perhaps  to  99°  F.,  following  the  initial  drop 
a  few  hours  after  the  injury.  In  cerebral  laceration  one  finds 
a  higher  initial  temperature  than  in  hemorrhage,  and  in  fatal 
cases   the   temperature   remains   elevated.     If   the   temperature 


TREATMENT  OF  FRACTURES  OF  THE)  SKULL         39 

rises  quickly  and  early,  a  considerable  laceration  is  present; 
if  after  several  hours  of  unconsciousness  the  temperature  re- 
mains about  99°  or  99.5°  F.,  there  is  probably  a  hemorrhage 
rather  than  a  severe  direct  lesion;  if,  on  the  other  hand,  the 
temperature  rises  higher,  there  is  a  cerebral  lesion,  alone  or 
associated  with  a  hemorrhage.  If  the  temperature  does  not 
rise  very  high  and  advances  rather  slowly,  there  is  a  contusion 
or  a  concussion  with  slight  laceration  or  a  slight  hemorrhage. 
A  slow,  full  pulse  with  stertorous  respiration  suggests  pressure; 
it  may  be  from  extradural  hemorrhage.  Early  and  very  slow 
respiration  is  associated  with  pressure  upon  the  medulla. 

Paralysis  of  the  limbs  and  the  face  is  characteristic  of  serous 
exudation,  hemorrhage,  or  bony  pressure.  Irregular  muscular 
contractions  suggest  laceration  of  motor  areas.  Mental  dis- 
turbance may  be  due  to  cerebral  lesions.  That  brain-tissue 
escapes  from  the  ear  does  not  necessarily  signify  that  the  patient 
will  not  recover.  Fractures  of  the  base  of  the  skull  occur  with- 
out marked  symptoms  and  recover  without  the  necessity  of 
operation. 

Peculiarities  of  the  child's  skull  which  must  be  considered  in 
interpreting  the  lesion  following  trauma  to  the  head: 

1.  The  bones  of  the  vault  are  very  elastic:  Trauma  usually 
causes  a  bending  of  the  bone  over  a  considerable  area.  The 
large  area  of  fibrous  tissue  between  the  skull  bones  prevents  the 
transmission  of  force  to  the  base  of  the  skull  from  the  vertex; 
hence  basal  fractures  are  rather  unusual  in  children. 

2.  The  diploe  is  absent.  There  is,  therefore,  no  distinction 
between  a  fracture  of  the  inner  or  outer  table;  both  tables  are 
involved  if  either  is  fractured. 

3.  The  air  sinuses  are  absent  or  very  little  developed;  this  fact 
is  of  importance  in  injuries  to  the  frontal  region  of  the  skull. 

4.  The  greater  adherence  of  the  dura  may  help  to  prevent  an 
extensive  extradural  hemorrhage. 

Treatment. — The  important  indication  for  treatment  is  the 
needed  reUef  of  an  increased  intracranial  pressure,  whether  of 
local  or  of  general  extent.  This  increase  of  intracranial  pressure 
may  be  due  to  a  depressed  fracture  of  the  skull,  to  a  blood-clot, 
or  to  edema.     If  the  two  former  conditions  exist,  a  local  operation 


40  FRACTURES    OF    THE    SKULL 

will  suffice.  If,  however,  a  general  edema  exists,  then  a  decom- 
pression operation  by  opening  the  skull  will  afford  temporary 
and  possibly  permanent  relief. 

There  are  cases  of  injury  to  the  skull  so  serious  that  it  is  evi- 
dent that  operation  will  be  of  no  avail.  There  are  cases  of  simple 
concussion  in  which  only  careful  nursing  is  demanded.  There 
is  a  large  and  increasing  number  of  serious  head  accidents  in 
which  operative  interference  will  prove  of  great  value.  The 
collapse  from  shock  may  be  well-nigh  complete,  but  restora- 
tive measures  are  not  to  be  neglected  upon  this  account.  If 
hemorrhage  is  suspected,  stimulation  of  the  circulation  must 
be  very  guarded.  The  patient  should  be  placed  horizontally, 
with  the  head  shghtly  raised,  and  kept  quiet.  The  whole  body 
should  be  wrapped  in  warm  blankets.  Warm  water  bottles 
should  be  put  on  the  outside  of  the  bed  about  the  patient,  not 
next  the  skin,  one  at  each  foot,  three  along  each  side  of  the  body. 
The  water  in  these  bottles  should  be  comfortablv  warmed 
— iio°  F.  Hot  water  is  never  to  be  used.  Patients  under 
these  circumstances  are  insensible  to  heat,  and  severe  burn- 
ing of  the  skin  may  occur  if  very  hot  water  is  used  in  the 
bottles. 

If  there  are  no  indications  for  immediate  operation,  and  local- 
izing symptoms  are  absent,  the  patient  is  to  be  treated  sympto- 
matically.  The  pulse  is  to  be  carefully  watched  to  detect  varia- 
tions in  strength,  rate,  and  rhythm.  The  character  and  fre- 
quency of  the  breathing  are  to  be  likewise  noted.  Gentle  stimu- 
lation subcutaneously  by  sulphate  of  strychnin  {-^-q  of  a  grain), 
administered  as  needed,  will  often  steady  a  pulse  remarkably. 
A  special  nurse  or  an  intelligent  watcher  should  be  with  the 
patient  constantly,  to  note  any  localizing  signs  of  pressure,  such 
as  twitching  of  the  muscles  of  the  face  or  limbs  and  variations 
in  the  pupil,  to  record  movements  of  the  limbs,  and  to  make 
hourly  obseiA^ations  of  the  pulse,  temperature,  and  respiration, 
and  any  variation  in  consciousness.  These  observations  will 
be  of  inestimable  value  in  determining  diagnosis,  prognosis, 
and  treatment. 

The  prompt  administration  of  urotropin  is  indicated  in  case  of 
injury  to  the  base  of  the  skull  with  threatened  infection  (Crowe). 


TREATMENT  OF  FRACTURES  OF  THE  SKULL         4 1 

It  has  been  found  that  if  urotropin  is  given  by  mouth,  evidences  of 
its  presence  in  the  cerebrospinal  fluid  are  clear.  The  largest 
amount  of  urotropin  is  present  in  the  cerebrospinal  fluid  from 
thirty  minutes  to  one  hour  after  the  ingestion  of  the  drug.  The 
amount  present  is  supposed  to  be  sufficient  to  combat  a  beginning 
infection.     It  is  present  in  the  form  of  formaldehyd. 

The  various  cavities  exposing  the  brain  to  infection  should  be 
cleansed. 

The  Nose. — ^The  nose  should  be  douched  with  boric  acid  solu- 
tion (i  :3o),  and  wisps  of  sterilized  absorbent  cotton  should  be 
placed  loosely  in  each  nostril.  If,  for  any  reason,  douching  seems 
unwise,  swabbing  all  visible  blood-clot  away  and  simply  wiping 
the  nose  carefully  will  probably  suffice.  It  is  important  not  to 
produce  a  sneeze,  for  septic  material  may  be  driven  into  the  middle 
ear  or  ethmoidal  cells  and  may  be  the  cause  of  a  septic  menin- 
gitis (Gushing). 

The  Ear.— The  ear  (i.  e.,  the  external  auditory  canal)  should  be 
wiped  with  boric  acid  solution  (i  :  30)  and  dried  carefully  with 
small  wisps  of  cotton.  Boric  acid  powder  should  then  be  blown 
gently  into  the  external  auditory  meatus.  A  bit  of  steriHzed 
gauze  or  absorbent  cotton  may  be  left  loosely  in  the  external 
auditory  meatus. 

The  Scalp. — The  directions  for  cleansing  the  scalp  apply 
to  cases  with  or  without  scalp  wounds  associated  with  import- 
ant cerebral  symptoms.  The  whole  scalp  should  be  shaved, 
scrubbed  with  hot  water  and  soap,  with  chlorinated  soda  solu- 
tion (i  :2o),  with  boiled  water,  and  then  with  alcohol  (70  per 
cent.),  and  covered  with  a  dressing  of  sterilized  gauze.  The 
wound  of  the  soft  parts  should  be  carefully  irrigated  with 
sterilized  salt  solution,  and  sponged  and  swabbed  with  great  care 
with  corrosive  subhmate  solution  ( i  :  5000) .  The  swabs  used 
should  be  tiny  ones,  so  as  to  reach  to  the  smallest  recesses  of  the 
wound.  Corrosive  sublimate  solution  should  not  be  allowed  to 
touch  the  brain-tissue. 

The  Motdh. — Thorough  cleaning,  with  corrosive  sublimate  solu- 
tion (i  :  3000),  of  the  teeth  and  tongue  and  all  the  folds  of  the 
mucous  membrane  about  the  lower  and  upper  jaws  is  important. 
The  swabbing  of  the  tonsils  and  the  posterior  pharyngeal  wall. 


42 


FRACTURES   OF   THE    SKULL 


the  care  of  the  nose  and  the  ear — these  procedures  will  reduce  to 
a  minimum  the  chances  of  infection.  The  nose  and  mouth  will 
require  constant  attention.  The  ear  will  require  at  least  daily 
cleansing.  The  frequency  of  the  cleansing  required  will  depend 
very  largely  upon  the  amount  of  moisture  and  discharge  from 
the  part  involved.     If  the  cotton  wisps  soon  become  moistened, 


yiiOi^H^ 


Fig.  19. — Sites  where  extradural  hemorrhage  is  usually  found. 

the  cleansing  should  be  repeated,  and  fresh,  dry  cotton  replace 
the  old. 

If  there  is  great  restlessness,  it  may  be  necessary  to  restrain 
the  patient,  that  he  may  not  harm  himself.  This  is  done  by 
means  of  a  sheet  folded  and  passed  about  the  bed  and  body 
of  the  patient. 

These  cases  of  suspected  fracture  of  the  base  are  to  be  very  care- 
fully watched.  They  should  be  kept  in  bed  for  two  or  three  weeks, 
quietly  resting,  so  that  any  existing  fracture  may  heal.  The  pa- 
tient is  ignorant  of  the  concealed  danger  from  a  basal  fracture. 
He  cannot  appreciate  the  importance  of  rest.  Rest  should  be 
enforced. 

Operative  interferetice  is  demanded  in  penetrating  or  sharply 


TREATMENT  OF  FRACTURES  OF  THE  SKULL 


43 


depressed  fractures,  in  all  compound  fractures,  and  in  all  simple 
fractures  with  symptoms  of  intracranial  hemorrhage  increasing 
in  severity  or  distinctly  locaHzed  (see  Figs.  19,  20,  21).  A  local- 
ized compound  depressed  fracture  of  the  occiput  over  the  cere- 
bellum without  serious  symptoms  may  be  an  exception  to  this 
statement  of  operative  treatment. 


Fig.  20. — Location  of  anterior  branch  of  middle  meningeal  artery.  Draw  a  line  from  the 
glabella  backward  (a  d),  parallel  to  the  line  b  c,  from  the  lower  edge  of  the  orbit  tiirough  the 
external  meatus.  Line  from  glabella  to  mastoid,  a  e.  From  the  middle  of  this  last  line,  a  line 
drawn  perpendicular  to  it  will  intersect  the  line  a  d  at  about  the  site  of  the  artery.  A  line  running 
from  the  front  of  the  mastoid  perpendicular  to  the  line  b  c  intersects  a  d  slI  about  the  site  of  the  pos- 
terior branch  (after  Eisendrath). 

If  a  hemorrhage  from  the  middle  meningeal  artery  is  suspected 
and  the  removal  of  the  bone  upon  one  side  of  the  skull  does  not  dis- 
cover a  hemorrhage,  the  skull  should  be  trephined  upon  the 
opposite  side.  All  the  blood -clot  that  can  be  removed  with  ease 
should  be  wiped  away  with  soft  gauze  or  gently  washed  away  by 
a  stream  of  warm  salt  solution.  If  bleeding  from  the  artery  cannot 
be  checked  by  ligation  of  the  vessel  because  of  its  inaccessibility, 
it  may  be  controlled  by  gauze  packing.  This  packing  should  be 
removed  at  an  early  hour  subsequently,  so  as  to  avoid  the  intra- 


44 


FRACTURES    OF    THE    SKUIvL 


cranial  pressure  caused  by  the  presence  of  the  gauze.  If  the 
iDleeding  is  from  a  sinus  or  some  unrecognized  source,  gauze 
packing  wih  check  it. 

Operation  should  be  undertaken  in  these  cases  for  three  distinct 
reasons:  to  insure  cleanhness,  to  elevate  and,  if  necessary,  remove 
bony  fragments,  and  to  remove  blood-clot  and  to  check  hemor- 
rhage. The  details  of  operative  treatment  must  necessarily  be 
omitted. 

All  cases  of  injury  to  the  head,  even  cases  of  simple  non-de- 


■--'"j'.i/' 

Fig.  2  1. — Perpendicular  lines  from  the  mastoid  and  from  just  in  front  of  the  ear  include  the  motor 
area  of  the  central  convolutions.     The  fissure  of  Rolando  is  shown. 

pressed  fracture  of  the  skull  without  symptoms,  are  to  be  watched 
with  great  care  by  trained  observers  for  at  least  one  month 
following  the  accident,  and  then  are  to  be  seen  at  intervals  for 
many  months  afterward.  The  reason  for  this  prolonged  ob- 
servation is  that  meningeal  hemorrhage  may  develop  in  the 
immediate  future,  and  that  after  an  interval  of  months  a  brain- 
abscess  may  manifest  its  presence. 

In  fracture  of  the  base  with  pronounced  symptoms,  drainage 
of  the  fossa  involved,  whether  anterior,  middle  or  posterior, 
should  be  considered.     It  has  been  of  service. 


TREATMENT  OF  FRACTURES  OF  THE  SKULL         45 

In  the  case  of  a  primarily  and  often  a  secondarily  unconscious 
person  with  fracture  of  the  base  of  the  skull,  an  operation  of 
decompression,  according  to  Cushing's  suggestion,  is  to  be  tried. 
The  opening  made  in  the  temporal  region  by  splitting  the  temporal 
muscle,  removing  the  squamous  portion  of  the  temporal  bone, 
exposes  the  region  of  the  meningeal  arter}-.  The  dura  should  be 
opened.  The  wound  closed  without  drainage  leaves  a  musculo- 
cutaneous covering.  This  procedure  may  relieve  intracranial 
pressure  effectually.  In  a  certain  series  of  basilar  fractures  so 
treated  the  mortality  has  been  decidedly  low.  Alwavs  consider 
in  a  case  of  basilar  fracture  the  wisdom  of  a  Gushing  decompres- 
sion operation. 

Obviously,  if  there  is  present  a  hematoma  in  the  occipital  or 
mastoid  region,  indicating  a  serious  lesion  of  the  posterior  fossa, 
any  decompressive  operation  should  seek  to  relieve  the  increased 
tension  beneath  the  tentorium.  A  subtentorial  trephining  will 
be  necessary.  Trephining  the  skull  above  the  level  of  the  ten- 
torium v/ill  probably  not  relieve  the  subtentorial  pressure  very 
materially. 

Prognosis. — A  concussion  of  the  brain  must  have  a  circum- 
spect prognosis  attached  to  it,  both  immediately  and  remotely. 
Edema  of  the  meninges  and  brain  may  follow  a  simple  concus- 
sion and  prolong  the  convalescence,  even  giving  rise  to  compres- 
sion of  cranial  contents  and  focal  symptoms.  Prolonged  mental 
depression  and  severe  headache  may  follow  concussion.  The 
prognosis  of  head  injuries  is  the  prognosis  of  their  complica- 
tions and  sequelge.  Prolonged  unconsciousness  is  not  usually 
dangerous  in  itself. 

Tate  unconsciousness  is  dangerous.  The  late  development  of 
coma,  indicative  of  recurring  extra  hemorrhage,  cerebral  edema, 
or  infection,  may  appear  following  a  subdural  bleeding,  particu- 
larly of  pial  origin.  The  severity  together  with  the  form  of  the 
lesion  is  to  be  made  the  basis  of  prognosis. 

When  there  is  a  fracture  through  the  anterior  fossa  there  is 
danger  of  septic  infection  through  the  nose  because  of  the  fracture 
of  the  horizontal  plate  of  the  ethmoid. 

There  is  a  great  mortality  attending  fractures  of  the  base  of  the 
skull  associated  with  much  bleeding  from  the  nose. 


46  FRACTURES    OF    THE    SKULL 

If  the  middle  fossa  is  fractured  infection  may  arise  through  the 
nasopharynx  and  ear;  the  middle  meningeal  artery  may  be  torn 
or  the  carotid  artery  lacerated. 

If  the  fracture  involve  the  posterior  fossa,  venous  sinuses  may 
be  damaged. 

The  prognosis  will  vary  therefore  according  to  the  fossa  involved 
in  the  fracture.  Apparently,  the  mortality  increases  as  the  injury 
moves  from  before  backward.  The  mortality  is  least  when  the 
anterior  fossa  is  fractured,  greater  when  the  middle  fossa  is  frac- 
tured, and  greatest  when  the  fracture  is  through  the  posterior 
fossa.  The  proximity  of  the  medulla  and  vital  centers  to  the 
fracture  in  the  posterior  fossa  increases  the  mortality  very 
appreciably. 

The  observations  of  many  fractures  of  the  base  lead  one  to  place 
considerable  importance  in  the  pupillary  reactions  in  determining 
the  prognosis  of  these  cases.  If  the  pupils  fail  to  react  {i.  e., 
dilatation  of  the  pupil  with  absolute  fixation)  the  prognosis  is 
grave.  Failure  of  the  pupils  to  react  following  a  basilar  fracture 
is  almost  always  a  fatal  sign.  The  temperature  is  of  great  value  in 
prognosis.  By  its  persistent  depression  the  danger  from  primary 
shock  is  gauged ;  a  little  later  in  the  course  of  the  case  the  amount  of 
hemorrhage  is  judged  by  it;  later  still,  its  rapid  and  progressive 
rise  will  denote  the  magnitude  or  severity  of  a  meningeal  or  cere- 
bral lesion.  A  temperature  as  high  as  105  °  F.  is  of  grave  progno- 
sis. This  elevation  to  105°  F.  has  been  called  the  "temperature 
dead  line,"  so  fatal  are  cases  under  these  conditions.  A  sud- 
den rise  of  temperature  late  in  the  progress  of  a  case,  probably 
due  to  meningitis,  or  a  continued  subnormal  temperature  at 
any  time  after  the  reaction  from  the  primary  shock,  is  always 
an  unfavorable  sign. 

There  is  always  great  doubt  as  to  the  outcome  of  traumatic 
lesions,  particularly  during  the  first  few  days  after  the  receipt 
of  the  trauma.  The  prognosis  will  be  altered  each  succeeding 
day  to  correspond  with  changed  conditions.  A  most  serious  situ- 
ation following  a  head  injury  may  clear  up  unexpectedly.  A 
case  apparently  progressing  satisfactorily  may  assume  suddenly 
a  grave  aspect.  One's  prognosis  must,  therefore,  always  be 
guarded. 


LATER    RESULTS    OF    INJURIES    TO    THE    HEAD  47 

LATER  RESULTS  OF  INJURIES  TO  THE  HEAD 

That  certain  remote  effects  result  from  trauma  to  the  head  is 
becoming  more  evident  as  larger  numbers  of  persons  are  examined 
by  competent  observers  months  and  years  after  injury.  The 
paper  by  English  (see  Bibliography)  is  notable,  and  the  following 
facts  are  of  importance.  A  knowledge  of  these  remote  conse- 
quences of  head-injury  is  important,  both  clinically  and  medico- 
legally. 

Unfortunately  immediate  recovery  from  a  head -injury  may 
not  always  imply  permanent  health.  Of  two  hundred  injuries  of 
the  head  carefully  followed  by  English  after  apparent  immediate 
recovery  39  per  cent,  showed  no  effects  afterward,  46  per  cent, 
showed  slight  signs  of  trouble  which  did  not  seriously  deter 
from  earning  a  Uving,  14  per  cent,  showed  marked  symptoms 
which  prevented  the  individual  from  working.  In  over  10  per 
cent,  of  the  cases  there  existed  some  degree  of  mental  impairment. 

Before  deciding  that  any  symptom  or  group  of  symptoms  is 
to  be  attributed  to  a  definite  head-injury  it  is  important  to  know 
whether  such  symptoms  have  occurred  in  this  individual  pre- 
vious to  the  accident.  The  accident  may  have  no  causative  rela- 
tion. A  malingerer  must  be  detected.  Several  examinations 
upon  successive  days  should  be  made  for  the  sake  of  accuracy. 

The  following  are  found  to  be  some  of  the  later  effects  of  head- 
injuries  : 

Chronic  headache,  which  may  be  general,  over  a  large  (fron- 
tal, occipital,  etc.)  area  of  the  head,  or  local,  corresponding  to 
definite  scars  in  the  scalp,  or  to  tender  areas  upon  the  skull  or 
neuralgic-like,  along  the  course  of  certain  nerve-trunks.  Along 
with  these  chronic  headaches  are  associated  insomnia,  mental 
depression,  loss  of  appetite,  inability  to  do  any  work,  and  a  char- 
acteristically marked  aspect.  At  times  painful  and  tender  cica- 
trices in  the  scalp  are  discovered,  which  are  significant. 

Vertigo  occurs  in  many  cases,  and  is  often  very  persistent. 
Vomiting  is  associated  with  headache  and  vertigo. 

Changes  of  character  appear.  Persistent  depression  and  mel- 
ancholy are  evident.  There  is  often  great  mental  irritability. 
The  individual  "  loses  his  nerve."    An  increased  susceptibility  to 


48  FRACTURES    OF    THE    SKULL 

the  effect  of  alcohol  is  not  uncommon.  An  inability  for  mental 
and  physical  exertion  is  prominent.  There  is  disturbed  sleep. 
The  high  climatic  temperatures  are  quickly  felt.  Sunstroke  is 
common. 

The  following  conditions  are  enumerated  as  having  been 
noted  in  a  study  of  these  cases.  Motor  aphasia,  traumatic 
amnesia,  agraphia,  loss  or  impairment  of  the  arithmetical  faculty 
and  the  musical  faculty;  certain  lesions  of  the  cranial  nerves 
are  often  noted  after  head -injuries  which  help  to  localize  the 
fracture  or  injury  to  the  brain,  such  are,  loss  of  smell  when  the 
cribriform  plate  is  broken ;  inequality  of  the  pupils ;  accommodative 
asthenopia;  nystagmus;  facial  paralysis,  although  several  cases 
of  paralysis  of  the  seventh  nerve  have  eventually  completelv 
recovered  ;  deafness  ;  glycosuria,  and  hemiplegia  are  both 
recorded  as  closely  following  injury  to  the  head. 

In  order  to  avoid  these  unpleasant  after-effects  of  head -injury, 
or  at  least  to  minimize  them,  it  is  essentially  important  that 
sufficient  mental  rest  should  be  observed  following  the  apparent 
early  recovery.  A  forced  mental  rest  is  important.  It  should 
be  insisted  upon  by  the  attending  physician.  No  head-in  jurv, 
however  trivial,  should  be  regarded  as  unimportant  and 
be  made  light  of  to  the  patient  or  the  patient's  friends.  Trephining 
of  the  skull,  when  any  local  indications  of  bone  cicatrix  or  scalp 
cicatrix  are  present,  may  reveal  changes  in  the  dura  and  under- 
lying brain  which,  by  excision  or  because  of  the  change  of  pres- 
sure occasioned  by  the  exploration,  will  cease  to  be  irritative 
lesions. 

Chronic  cerebral  abscess  may  follow  slight  trauma  to  the  head 
with  almost  unnoticed  cerebral  disturbance.  Becoming  walled 
off  from  the  brain-tissue  the  abscess  may  act  like  a  brain  tumor, 
and  if  it  chance  to  lie  in  a  silent  portion  of  the  brain  causes  no 
symptoms  until  months  or  years  afterward,  when  drainage  of 
such  a  focus  will  probably  relieve  the  situation  permanently. 

Traumatic  epilepsy  is  another  undoubted  and  unfortunate 
result  of  injury  to  the  head.  Probably  few  cases  of  traumatic 
epilepsy  would  exist  if  all  depressed  bony  fragments  were  thor- 
oughly  elevated    at   the   time  of    the  original   trauma.      What 


ILLUSTRATIVE    CASES  49 

cases  of  traumatic  epilepsy  are  suitable  for  operative  interference  ? 
There  must  be  evidence  of  a  definite  injury,  the  epilepsy  must 
be  localized — i.  e.,  Jacksonian— in  type;  the  individual  should  not 
have  suffered  for  more  than  two  years,  and  there  should  be  no 
decided  neurotic  family  taint.  Under  these  conditions  opera- 
tion may  afford  relief  for  a  few  months  or  even  so  long  as  three 
years,  but  rarely  for  a  longer  period.  During  this  period  the 
bromids  should  be  administered  as  well. 

Insanity. — Mental  impairment  is  not  uncommon  after  head 
injuries,  yet  the  degree  of  change  from  the  normal  individual  is 
rarely  so  great  as  to  include  it  under  the  heading  of  insanity. 

Insanity  may  result,  however,  from  injury  to  any  part  of  the 
head.  Those  cases  of  traumatic  insanity  which  present  a  IocrHz- 
ing  indication  are  likely  to  be  relieved  by  operation ;  and  in  only 
this  class  is  operation  justifiable.  The  results  from  operation  in 
suitable  cases  are  satisfactory.  The  alternative,  if  no  operation 
is  done,  is  hopeless  in  the  extreme. 

Dr.  Bullard,  of  the  Boston  City  Hospital,  has  contributed  so 
valuable  a  paper  upon  this  subject  that  the  results  are  here  stated : 
Seventy  patients  were  examined  after  having  had  fracture  of  the 
skull;  37  presented  no  symptoms  when  examined  some  time  later. 
The  most  frequent  consequences  were  headache,  deafness,  dizzi- 
ness, and  inability  to  resist  the  action  of  alcohol  on  the  brain. 
Out  of  15  cases  in  which  operation  (trephining)  was  performed, 
1 2  had  no  resulting  symptoms ;  in  one  case  it  was  doubtful  whether 
the  symptoms  present  were  due  to  injury;  in  one  case  the  symp- 
toms were  slight  (headache  rare,  tension  over  the  wound  while 
lying  in  bed).  The  other  case  was  deaf,  but  had  no  other 
trouble. 

Dr.  Bullard  concludes,  so  far  as  these  statistics  lead,  that 
those  cases  in  which  trephining  was  performed  have  shown 
much  better  results,  so  far  as  the  symptoms  previously  men- 
tioned are  concerned,  than  those  in  which  no  operation  was 
performed. 

CASES  OF  HEAD  INJURY 

The  following  cases,  related   in  some  detail,  illustrate  a  few  of 

the  varieties  of  injuries  to  the  head  from  a  clinical  standpoint: 

4 


50  INJURIES    TO    the;    HEAD 

Case  I. — A  fall  upon  the  head. — No  visible  evidences  of  injury. — An 
interim!  of  consciousness  followed  by  ttncotisciousness. — Localizing  signs 
of  pressure. — JDiagtiosis,  middle  meningeal  hetnorrhage  with  fracture 
of  skull.  —  Operation. — Fi'acture  a7id  hemorrhage  found. — Recovery. 

M.   A.   B ,  sixty-nine  years   old,  a  spinster,   fell,   upon  being 

struck  by  a  coasting-sled,  one  and  one-half  hours  previous  to  the 
examination. 

Examination. — She  does  not  know  of  the  accident  which  has  be- 
fallen her.  She  talks  coherently.  She  recognizes  her  sister.  There 
is  slight  shock.  The  pulse  is  64  and  of  fair  strength  ;  the  respira- 
tion is  16  ;  the  temperature  is  97.5°  F.  There  is  bleeding  from  the 
right  ear.  There  is  some  dry  blood  about  the  nostrils.  There  is  no 
visible  external  injury.  There  is  no  paralysis.  All  the  superficial 
reflexes  are  present.  The  pupils  are  contracted  equally  and  react  to 
light.  The  patient  is  not  very  restless,  although  she  talks  consider- 
ably and  affirms  again  and  again  that  she  is  not  hurt. 

The  ears  were  washed  out  carefully  and  treated  antiseptically. 

She  vomited  two  or  three  times  during  the  night.  She  was  quite 
restless,  moving  and  turning  in  bed.  She  slept  two  or  three  hours 
altogether.  There  were  no  evidences  of  intracranial  pressure  in  the 
morning.  At  about  noon  of  the  second  day  she  talked  a  little  inco- 
herently.    She  did  not  answer  questions  as  readily  as  in  the  morning. 

At  3  o'clock  in  the  afternoon  of  the  second  day  examination  finds 
the  pupils  equal  and  reacting  to  light.  She  understands  what  is  said 
to  her,  but  does  not  talk  coherently  or  distinctly.  There  is  almost 
complete  paralysis  of  the  right  arm.  There  is  paresis  of  the  right  leg. 
The  face  is  not  paralyzed.  The  pulse  has  increased  in  rate  to  85  and 
is  particularly  full  and  bounding.  The  knee-jerk  is  much  less  active 
upon  the  right  than  upon  the  left  side. 

At  4.30  P.M.,  one  and  one-half  hours  after  the  previous  observa- 
tion, all  the  symptoms  were  considerably  intensified.  The  face  was 
uneven,  the  wrinkles  being  most  marked  on  the  left.  The  breathing 
was  becoming  labored  and  almost  stertorous.  It  was  hard  to  arouse 
the  woman.  She  moved  the  left  arm  freely.  The  right  arm  she  moved 
slightly  or  not  at  all.  There  were  no  abdominal  reflexes  active.  Bleed- 
ing from  the  right  ear  continued  to  a  slight  extent  all  day. 

A  diagnosis  of  middle  meningeal  hemorrhage  on  the  left  side  was 
made.     Immediate  operation  was  decided  upon. 

Under  ether  anesthesia  an  elliptic  incision  was  made  upon  the  left 
side  of  the  head,  beginning  just  in  front  of  the  ear,  and  was  carried 
up  across  the  temporal  muscle  and  down  to  the  zygoma  of  the  same 
side.  A  quarter-inch  trephine  was  used.  The  hemorrhage  was  found 
to  be  from  a  branch  of  the  middle  meningeal  artery,  and  from  within 
the  dura,  which  was  lacerated.  A  large  clot  and  much  fresh  blood 
were  lying  over  the  temporal  and  parietal  regions.  This  blood  was 
carefully  sponged  away.  The  middle  meningeal  branch  was  tied 
with  a  silk  ligature.  Gauze  wicks  were  placed  well  down  deep 
toward  the  base  of  the  skull.     The  dura  was  not  sutured.     The  bleed- 


ILLUSTRATIVE    CASES 


51 


ing  vessels  of  the  diploe  were  stopped  with  wax.     The  skin  flap  was 
replaced  and  sutured,  leaving  a  small  gauze  drain  down  to  the  dura. 

The  pulse  was  poor,  and  there  was  evidence  of  considerable  shock 
at  the  conclusion  of  the  operation.  Proper  stimulation  with  strych- 
nin and  enemata  of  salt  solution 
and  brandy  had  a  good  effect. 
The  temperature  rose  to  110°  F. 
during  the  night,  but  dropped 
immediately  and  gradually  came 
to  normal. 

The  following  day  uncon- 
sciousness was  present,  the  par- 
alysis was  unrelieved,  the 
breathing  was  stertorous  and 
puffing. 

The  second  day  after  the  op- 
eration the  gauze  drain  was  re- 
moved and  two  smaller  gauze 
drains  were  inserted.  Some 
signs  of  consciousness  appear. 
She  takes  notice  of  people  com- 
ing into  the  room. 

The  fifth  day  following  the 
operation  she  notices  friends. 
The  paralysis  is  still  present. 

The  sixth  day  after  the  op- 
eration she  moves  the  right  leg 
a  little.      No  articulate  speech 

is  present.      Understands  questions  and  grunts  in  answer  to  all  ques- 
tions.     She  can  express  no  idea  in  words. 

The  tenth  day  after  the  operation  she  moves  the  right  arm.  The 
mental  condition  is  clearer. 

On  the  eighteenth  day  she  moves  the  right  leg,  and  the  arm  has 
more  power. 

The  thirtieth  day  was  an  important  one  for  the  patient.  She  walked 
alone  for  the  first  time  since  the  accident. 

One  year  after  the  accident  the  patient  is  found  to  be  having  occa- 
sional attacks  of  dizziness,  accompanied  by  ' '  falling-fits. ' '  She  is 
perfectly  sane,  and  talks,  often  very  well ;  then  there  come  times  of 
difficulty  in  talking,  when  she  can  not  find  the  right  word  to  express 
herself  Just  after  one  of  these  attacks  of  fainting,  etc.,  talking  is  less 
easy. 

Three  years  after  the  operation  the  following  examination  was  made  : 
The  speech  is  thick,  slow,  and  with  effort.  The  facial  muscles  of  the 
left  side  are  stiff  and  slightly  drawn  ;  they  do  not  move  so  well  as  on 
the  right  side.  The  left  nasolabial  fold  is  more  accentuated  than  the 
right.  The  left  eyebrow  is  lower  than  the  right.  The  patient  thinks 
that  she  can  hear  better  with  the  right  ear  than  with  the  left.  The 
right  hand  gets  cold  "and  does  not  look  natural."  The  right  fore- 
finger is  often  whiter  than  the  other  fingers  of  the  right  hand.      It  is 


Fig.  22. — Case  L     Line  of  incision  shown. 


52 


INJURIES    TO    THE    HEAD 


difl&cult  to  pick  up  needles  or  pins  with  the  fingers  of  the  right  hand. 
There  is  no  increase  in  the  wrist-jerks.  The  knee-jerk  is  slightly 
greater  on  the  right  side  than  on  the  left. 

The  patient  says  she  is  enjoying  excellent  health,  eats  and  sleeps 
well,  and  is  out  of  doors  much  of  the  time.     She  is  taking  bromid 

of  potassium  regularly*  once  a  day 
in  small  doses.  About  once  a  month 
she  has  a  fainting  or  ' '  weak  spell. ' ' 
These  attacks  are  growing  less  pro- 
nounced and  less  frequent. 

This  case  illustrates  the  important 
fact  that  after  a  severe  head  injury 
with  almost  no  external  visible  sign, 
the  patient  should  be  kept  under 
\ery  careful  observation  through  the 
hours  immediately  succeeding  the 
accident.  Relative  symptoms  are 
of  far  greater  importance  in  head 
injuries  than  isolated  observations. 
Bleeding  from  the  ear  as  a  symptom 
in  head  injuries  does  not  necessarily 
imply  fracture  of  the  petrous  portion 
of  the  temporal  bone.  Rupture  of 
the  tympanum  may  cause  bleeding 
from  the  ear.  There  was  no  frac- 
ture of  the  skull  detected  after  care- 
ful examination  in  this  case. 

The  interval  of  consciousness  in 
this  case  was  a  somewhat  short  and 
hazy  one.  Immediately  after  the  accident  the  woman, was  dazed,  and 
at  no  time  was  she  herself  mentally.  It  is  to  be  remembered  in  this 
connection  that  the  interval  of  clear  consciousness  may  be  so  masked 
by  the  symptoms  of  concussion  as  to  be  completely  overlooked. 

Case  II. — An  open  depi-essed  fracture  of  the  skull. — Absence  of 
unconsciousness. — Paralysis  of  one-half  of  the  body.  —  Operation. — 
Recovery. 

This  case  illustrates  that  consciousness  may  be  unimpaired  following 
an  injury  to  the  head  severe  enough  to  cause  paralysis. 

A  boy,  nine  years  old,  was  struck  on  the  head  by  a  brick  falling  from 
a  height.  He  was  seen  immediately  after  the  injury  and  found  to  be 
conscious.  He  answered  questions  naturally.  There  was  a  large 
scalp-wound  over  the  parietal  bone  and  a  little  anterior  to  the  parietal 
eminence  to  the  right  of  the  median  line.  The  bone  beneath  the 
scalp-wound  was  fractured  and  depressed  into  the  brain -substance. 
The  left  arm  and  the  left  leg  were  completely  paralyzed  to  motion. 
The  right  pupil  was  dilated  ;  sensation  was  present.  The  right  upper 
eyelid  drooped.  There  was  a  scar  in  the  right  cornea.  Immediately 
after  the  injury  the  temperature  was  96°  F.,  the  pulse  was  74,  the 
respiration  was  26.      When  examined  one  hour  after  the  accident  the 


Fig.  23.— Case  II.  Open  depressed  frac- 
ture of  the  skull  :  A',  the  mid-point  be- 
tween glabella  and  inion ;  A,  middle  of 
depressed  bone. 


ILLUSTRATIVE    CASES 


53 


pulse  had  fallen  to  68,  he  had  vomited  once,  and  had  been  somewhat 
nauseated. 

The  operation  of  elevation  of  the  depressed  fragments  of  bone  was 
done  under  ether.  The  fragments  of  bone  removed  were  aVjout  the 
size  of  a  silver  half-dollar.  There  was  no  fissure  in  the  skull.  The 
dura  mater  was  torn  and  the  brain  slightly  lacerated.  Upon  elevating 
and  removing  the  depressed  bone  hemorrhage  occurred  from  the  ves- 
sels of  the  dura  mater.  The  depressed  bone  was  not  replaced.  The 
dura  was  left  open  and  the  cavity  was  drained  by  a  wick  of  gauze, 
which  was  removed  upon  the  third  day. 

A  few  hours  after  the  operation  the  boy  was  perfectly  conscious  as 
before  the  etherization,  the  pupils  were  normal,  and  motion  had 
returned  in  the  paralyzed  limbs. 


Fig.  24.— Case  III. 


Three  weeks  after  the  operation  a  small,  granulating  wound  remained 
and  there  was  a  slight  tendency  to  hernia  cerebri. 

Four  months  following  the  accident  the  boy's  condition  is  as  fol- 
lows :  The  wound  is  nearly  healed  and  continues  to  discharge  at  times. 
He  walks  naturally.  There  is  no  paralysis  of  arm  or  leg.  No  mental 
symptom  is  present. 

The  interesting  and  unusual  fact  in  this  case  is  that  after  a  blow 
sufficiently  severe  to  cause  a  depressed  fracture  of  the  skull  and 
paralysis  of  one-half  of  the  body  the  patient  remained  conscious. 

The  exact  location  of  the  injury  to  the  head  and  brain  is  shown  in 
figure  23. 

Case  III. — A  blow  upon  the  head. — Unconsciousness  immediate. — 
Slight  bulging  of  right  eye. — Middle  meningeal  hemorrhage. — Frac- 
ture of  skull.  —  Operation. — Recovery. 

Examination  found  edema  of  the  right  temporal  region.      Uncon- 


54  INJURIES    TO    THE    HEAD 

sciousness  present.  An  interval  of  consciousness  was  absent.  Slight 
bulging  of  the  right  eye. 

Operation  in  the  right  temporal  region.  A  skin-flap  was  made  over 
the  fracture  and  edematous  area.  A  fracture  was  detected  running 
from  about  the  middle  of  the  temporal  ridge  an  inch  back  of  the 
coronal  suture  outward  and  forward  across  the  squamous  part  of  the 
temporal  bone  to  a  half-inch  behind  the  pterion. 

The  bone  anteriorly  to  the  fracture  was  depressed.  The  trephine 
was  applied  over  the  depressed  portion  behind  the  coronal  suture. 
Upon  exposing  the  dura  no  pulsation  was  seen.  The  dura  was  dark 
in  color.  A  slight  amount  of  extradural  blood  escaped.  On  follow- 
ing the  fracture  down  to  the  base  of  the  skull  the  dura  was  found 
lacerated,  the  anterior  branch  of  the  middle  meningeal  artery  was 
torn,  and  blood-clot  and  lacerated  brain-tissue  were  present.  The 
anterior  branch  of  the  middle  meningeal  artery  was  tied  and  the 
hemorrhage  ceased.  The  blood -clots  were  removed,  the  exposed  area 
was  cleansed  with  boiled  water,  and  gauze  drainage  introduced.  All 
the  gauze  was  remo^■ed  in  four  days.  No  unusual  symptoms  attended 
convalescence.     Recovery  was  complete  in  three  months  (see  Fig.  24). 

This  case  is  of  interest  because  no  fracture  was  detected  before  the 
operation,  and  it  was  supposed  that  the  bulging  of  the  eye  indicated 
an  increase  of  intracranial  pressure,  which  proved  to  be  true. 

The  method  of  operating  was  comparatively  simple,  in  that  the 
fracture  was  followed  down  until  the  bleeding  vessel  was  found.  This 
necessitated  the  free  removal  of  bone  below  the  trephine  opening. 

There  was  no  interval  of  consciousness  in  this  case,  and  the  condi- 
tions found  easily  explained  itr,  absence.  The  man  was  suffering  from 
concussion  and  laceration  of  the  brain  as  well  as  from  intracranial 
pressure,  and  the  inter\al  of  consciousness  was  obscured  by  the 
presence  of  the  concussion.  The  recognition  of  an  interval  of  con- 
sciousness is  of  very  great  importance.  If,  however,  the  interval  of 
consciousness  is  not  present,  as  in  the  case  reported,  intracranial  pres- 
sure from  hemorrhage  can  not  be  said  to  be  absent,  for  concussion 
attendant  upon  the  injury  may  mask  the  interval  of  consciousness 
which  might  have  been  present  had  the  injury  been  less  severe. 

Case  IV.  (Quoted  by  Crandon  and  Wilson). — An  injury  to  the 
head.  —  Unconsciousness. — Bleeding  from  ear.  —  Consciousness  returns. 
— Five  days  later  walks  about. — Sudden  Death. 

A  soldier  from  a  harbor  port  was  found  on  the  sidewalk  after  a  fall 
from  assault  or  accident.  Unconscious  ;  bleeding  from  left  ear,  hema- 
toma behind  it  ;  left  pupil  larger  than  right,  but  both  react  sluggishly  ; 
no  paralysis.  Consciousness  returned  in  a  few  hours,  bleeding  stopped, 
the  pupils  became  normal,  and  the  patient  was  quite  without  symptoms 
on  the  third  day.  On  the  fifth  day,  against  advice,  the  patient  insisted 
on  leaving  the  hospital,  boarded  the  steamer  and  reached  the  fort. 
He  stepped  ashore  and  dropped  dead.  The  autopsy  showed  a  fracture 
of  the  base  of  the  skull. 

This  Case  IV.  is  quoted  to  emphasize  the  very  great  importance  of 
proper  rest  after  a  serious  trauma  to  the  head.  See  paragraph  under 
Treatment,  p.  42. 


OBSTETRIC    FRACTURES.  55 

OBSTETRIC  FRACTURES 
Fractures  of  the  Skull. — Fractures  of  the  skull  in  the  new- 
born are  of  two  general  types  :  (i)  A  furrow-like  indentation, 
and  (2)  a  spoon-shaped  indentation.  The  furrow-shaped  fracture 
is  rarely  a  serious  affair.  The  seat  of  these  fractures  is  usually 
upon  the  parietal  or  frontal  bone  near  to  the  anterior  fontanelle. 

The  causes  of  these  spoon-shaped  fractures  are  various — 
a  deformity  of  the  maternal  pelvis  causing  moderate  obstruc- 
tion to  the  fetal  head  at  the  sacral  promontory  or  the  iliopectineal 
eminence,  a  prolonged  instrumental  labor,  a  defective  ossifica- 
tion of  the  fetal  skull,  a  prolapsed  upper  extremity,  and  last, 
but  most  doubtful  as  a  cause,  the  pressure  of  the  blades  of  the 
obstetric  forceps.  This  latter  is  a  doubtful  cause,  because  the 
pressure  of  the  forceps  usually  occasions  a  mere  furrow-Uke  inden- 
tation which  is  not  usually  serious. 

The  prognosis  of  these  depressions  in  the  newborn  skull  will 
vary  with  the  other  conditions  present,  viz.:  i.  If  the  child  is 
born  alive  and  seems  well  the  deformity  may  disappear  in  from 
one  to  two  weeks.  2.  It  may  remain  as  a  permanent  deformity. 
If  it  remains  a  permanent  deformity  there  may  arise  marked 
local  and  even  general  disturbances  which  may  result  fatally. 
Signs  of  disturbance  will  be  fretfulness  and  irritability,  a  dislike 
of  nursing,  twitching,  and  convulsions.  3.  The  child  may  be 
born  almost  dead  or  deeply  asph5rxiated.  If  the  fracture  (spoon- 
shaped)  is  not  immediately  reduced  the  child  will  die. 

Treatment. — The  treatment  of  these  cases  has  been,  in  the  four 
cases  recorded,  operation  and  elevation  of  the  depression  by  a 
blunt  steel  sound.  Kerr's  method  of  reduction  is  to  be  used 
when  applicable.  This  method  is  dependent  upon  the  fact  of 
the  resiliency  of  the  fetal  skull.  Kerr  finds  that  gentle,  firm 
compression  of  the  skull,  from  before  backward,  i.  e.,  antero- 
posteriorly,  will  result  in  an  immediate  disappearance  of  the 
spoon-shaped  depression.  If  the  indentation  is  low  down  on  the 
side  of  the  skull,  this  method  may  fail  and  operation  may  be 
necessary.  If  too  long  a  time  has  elapsed  since  the  occurrence 
of  the  deformity  it  may  be  impossible  to  reduce  it  by  the  simpler 
method.  No  spoon-shaped  depression  of  the  newborn  skull 
should  be  permitted  to  remain  permanently  unreduced. 


CHAPTER  II 
FRACTURES  OF  THE  BONES  OF  THE  FACE 

FRACTURES  OF  THE  NASAL  BONES 
Anatomy. — The  anatomical  relations  of  the  nasal  bones 
(to  the  perpendicular  plate  of  the  ethmoid,  the  vomer,  the  car- 
tilaginous septum,  the  superior  maxillary  bone,  and  the  frontal 
bone)  make  their  fracture  of  far  greater  importance  than  a  mere 
superficial  disfigurement  of  the  face  Avould  indicate  (see  Fig. 
25).       The   site   of    the   fracture   is  often  near  the  lower  edge 


Cribriform  plate. 


Frontal  sinus. 


Nasal  bone. 
Ethmoid  plate. 


Superior  maxilla. 


Sphenoidal  sinus. 


Fig.  25. — Median  section  of  nose. 


of  the  bone.  Most  fractures  of  the  nasal  bone  are  open  through 
either  the  skin  or  the  mucous  membrane.  In  nearly  all  nasal 
fractures  the  cartilage  of  the  septum  is  more  or  less  injured. 
The  upper  lateral  cartilages  may  be  torn  from  their  attachments 
to  the  nasal  bones,  simulating  fracture  of  these  bones.  The 
resulting  deformity  of  this  accident  is  well  illustrated  in  figure 
26.  A  high  fracture  of  the  nasal  bones  with  lateral  deformity 
is  shown  in  figure  28:  the  nasal  bone  of   one  side  has  been  im- 

56 


ANATOMY 


57 


Fig.  26. — Separation  of  cartilage  from  nasal 
bones  (Harrington). 


Fig    27. — -Fracture  and  lateral  displace- 
ment of  each  nasal  bone. 


Fig.  28. — Case  of  fracture  of  nasal  bones. 
Lateral  displacement  (Harrington). 


Fig.  29. — Fracture  and  lateral  displace- 
ment of  each  nasal  bone.  Side  view  of 
figure  27. 


58 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


pacted  with  the  frontal  bone,  and  the  nasofrontal  articulation 
upon  the  opposite  side  has  been  separated.  The  nasal  bone  that 
receives  the  fracturing  blow  is  broken  from  its  connections  and  is 
depressed  below  adjoining  bones  (see  Fig.  38).  The  nasal  bone 
on  the  side  opposite  the  blow  is  sprung  out  from  its  connections 
and  overlaps  them.  The  nasal  bones  are  separated,  therefore,  from 
proper  connection  with  each  other,  with  the  frontal  bone,  and  with 
the  nasal  process  of  the  superior  maxillary  bones.  These  facts 
must  be  kept  in  mind  in  attempting  reduction  of  fracture  of  the 


Fig.  30. — Syphilitic  deformity  (Harrington). 


Fig.  31. — Syphilitic  deformity  (same  case  as 
Fig.  30). 


nasal  bone.  Figures  27  and  29  show  a  case  in  which,  by  a  direct 
blow  squarely  upon  the  nasal  bones,  the  bones  were  separated  and 
one  was  laid  on  one  nasal  process  of  the  superior  maxillary  bone, 
and  the  other  was  laid  upon  the  corresponding  bone.  The  septum 
was  intact,  as  is  shown  by  the  persistence  of  the  natural  position 
of  the  tip  of  the  nose.  Figures  30  and  31  show  a  syphilitic  nose, 
the  septum  gone  and  the  nose  fallen  in.  The  contrast  in  these 
two  latter  cases  is  instructive. 

Symptoms. — Pain,  swelhng,  crepitus,  and  deformity  are  usu- 


COMPLICATIONS 


59 


ally  present.  The  subcutaneous  swelling  is  often  so  consider- 
able as  to  obscure  deformity.  Gentle  pressure  is  often  sufficient 
to  detect  crepitus  in  this  fracture,  when  a  firm  grasp  determines 
little  or  nothing. 

Complications. — Through  infection  of  the  internal  or  the 
external  wounds  suppuration  begins,  abscesses  form,  and  nec- 
rosis  of   bone    and   liquefaction   of   cartilage   may   occur.     Em- 


Fig-  .s2. — Case  of  open  fracture  of  the  nasal  bones.    Emphysema  over  the  forehead  and  the 

upper  part  of  the  face. 


physema  may  be  noticed  if  the  fracture  is  open  into  the  nasal 
cavity  (see  Fig.  32).  It  will  disappear  after  a  few  days  untreated. 
The  lachrymal  duct  may  be  obstructed  if  the  nasal  process  of 
the  superior  maxillary  bone  is  involved.  The  nasal  bone  may 
be  forced  up  into  the  floor  of  the  anterior  fossa  of  the  skull,  and 
cerebral  complications  arise  (see  Fig.  15).  If  the  deformity 
following  fracture  of  the  nasal  bones  is  not  corrected,  there  is 


6o 


FRACTURES  OF  THE)  BONES  OF  THE  FACE 


great  likelihood  of  trouble,  either  immediately  or  in  after  years, 
because  of  the  nasal  septum. 

The  Nasal  Septum  in  Fracture  of  the  Nose  (Figs.  33,  34,  35, 
36,  37).— The  starting  of  the  quadrilateral  cartilage  of  the  sep- 
tum at  some  of  its  bony  attachments  may  be  evident  at  once 
after  the  fracture  of  the  nose  as  a  marked  dislocation,  or  no 
change  may  be  seen  until  long  afterward,  when  a  ridge  due  to 
inflammatory  thickening  is  found  along  the  previously  loosened 
border.  The  septum  may  be  dislocated  from  its  attachment 
to  the  superior  maxilla,  and  deviate  into  one  nostril  or  the  other 
like  a  curtain.  The  commonest  dislocation  occurs  at  the  junc- 
tion of  the  cartilage  of  the  septum  with  the  vomer  and  the  eth- 
moid. 

Lesions  of  the  septum  due  to  fracture  occur  usually  in  the 
posterior  two-thirds  of  the  cartilaginous  and  in  the  anterior 
half  of  the  bony  septum.  Fractures  rarely  extend  through  the 
septum  to  the  posterior  nares.  In  fractures  of  the  nasal  bones 
with  little  displacement  the  septum  may  show  no  changes.  Even 
with  considerable  depression  and  comminution  of  the  nasal 
bones,  the  septum  as  a  whole  may  appear  unchanged,  the  lesions 
of  the  septum  being  confined  to  bowing  or  tearing  at  the  seat 


Fig-  53- 


Fig.  34-  Fig.  35.  Fig.  36. 

Figs.  33-37. — The  septum  in  fractures  of  the  nose  (Mosher). 


Fig.  37- 


of  fracture.  When  the  nasal  bones  are  much  deviated,  the  free 
edge  of  the  septum  deviates  with  them.  Fractures  of  the  nasal 
bones  may  occur  alone  or  in  combination  with  fractures  of  the 
septum.  Severe  cases  of  broken  nose  usually  combine  the 
two  conditions.  Fractures  of  the  septum  which  admit  of  classi- 
fication follow  one  of  two  types — horizontal  fractures  or  vertical 
fractures.     The   vertical   fracture   is   much   the   rarer.     It   may 


TREATMENT 


6i 


occur  anywhere  in  the  course  of  the  cartilaginous  septum,  but 
when  situated  well  back,  is  to  be  distinguished  from  dislocation 
of  the  cartilage.  The  horizontal  fracture  produces  a  gutter- 
like deformity  roughly  parallel  with  the  floor  of  the  nose.  The 
convexity  appears  in  one  naris,  the  concavity  in  the  other. 
Closely  allied  to  these  last  two  fractures  are  the  sigmoid  devia- 
tions, in  which  the  relation  to  fracture  is  unsettled.     They  are 


^ 

W  ■  ^  jiuM 

J 

Y  ' 

I' 

f 

^^^^ 

Jl 

'1 

,^^' 

./ 

~f 

Fip.  38. — Fracture  of  nasal  bones.     Elevation  of  depressed  bone  by  instrument   introduced 

into  the  nostril. 


so  common  that  they  are  mentioned  for  the  sake  of  complete- 
ness. The  name  describes  them.  They  occur  in  the  same 
two  types  as  the  angular  variety. 

Treatment. — The  nasal  cavity  should  be  inspected  by  mirror 
and  light  to  determine  any  lesion  of  the  septum.  Cocain  anes- 
thesia is  necessary  for  this  examination.  If  a  deviation  is  found, 
it  should  be  corrected  along  with  the  correction  of  the  external 
nasal  deformity.  For  this,  primary  anesthesia  will  be  needed, 
as  the  manipulation  is  extremely  painful.  By  external  manip- 
ulation combined  with  elevation  of  the  fragments  and  internal 
pressure  (see  Fig.  38)  the  deformity  can  be  overcome.  That 
nasal  bone  which  received  the  trauma  must  be  elevated  and  the 
opposite  nasal  bone  must  be  separated  from  the  superior  maxilla. 


62  FRACTURES  OF  THE  BONES  OF  THE  FACE 

This  is  accomplished  in  the  following  manner  (Mosher) :  A  flat 
elevator  is  placed  in  the  nose  well  up  under  the  depressed  nasal 
bone ;  the  thumb  of  the  left  hand  is  placed  against  the  second  nasal 
bone  where  it  overlaps  the  ascending  process  of  the  superior  max- 
illa. As  the  elevator  raises  the  first  bone  and  forces  it  outward, 
the  second  nasal  bone  is  raised  also  by  the  traction  in  the  skin  and 
periosteum,  so  that  its  outer  edge  is  unlocked  from  the  ascending 
process  of  the  maxilla.  Meantime,  thumb  pressure  forces  this 
last  bone  into  the  median  line.  In  this  manner  both  bones  are 
replaced  in  their  normal  positions.  Any  strong,  narrow,  and  thin 
instrument  will  be  of  service  as  an  elevator.  For  fractures  high  up 
with  displacement,  gauze  packing  carried  well  up  may  be  required 
to  retain  the  elevated  bones.  For  lower  deviations  the  Asch 
tube  may  be  needed.  If  the  nose  is  crushed,  it  will  be  necessary 
to  model  the  nose  over  the  Asch  tube,  one  being  placed  in  each 
nostril,  to  preserve  the  contour  and  lumen  of  the  nose.  If  there 
is  no  tendency  for  the  deformity  to  recur,  the  use  of  splints  is 
not  indicated.  Care  must  be  exercised  to  avoid  sudden  pressure 
on  the  nose  from  the  rough  use  of  the  pocket  handkerchief. 
In  the  treatment  of  these  cases  special  cleanliness,  perfect  drain- 
age, and  frequent  dressings  are  important.  If  there  is  a  recur- 
rence of  the  external  deformity,  localized  pressure  may  be  ex- 
erted in  various  ways,  all  of  which  are  more  or  less  unsatisfactory. 

The  tin  splint  fixed  to  the  forehead  by  a  circular  plaster 
band  is  of  service.  This  tin  splint,  made  from  ordinary  sheet 
tin,  consists  of  a  forehead  and  a  nasal  portion  moulded  to  the 
forehead  and  to  the  sides  of  the  nose.  The  nasal  portion  may 
be  twisted  or  bent  laterally  to  secure  the  desired  pressure  upon 
the  nose,  the  counterpressure  being  obtained  through  the  fixation 
secured  by  the  adhesive  plaster  band  to  the  forehead.  Repeated 
adjustments  of  this  splint  are  needed  to  make  it  of  continued 
efficiency ;  with  all  care,  however,  the  tin  splint  is  not  generally 
effective. 

The  use  of  adhesive  plaster  strips  (after  Davis)  from  cheek  or 
malar  bone  to  nose  with  small  compresses  is  of  limited  value. 

Cobb's  nasal  splint,  shown  in  figure  39,  is  expensive,  but  is 
very  satisfactory  for  making  direct  pressure  upon  the  nasal 
bones.     The  splint  is  made  of  a  band  of  steel,  fitted  to  the  head 


TREATMENT 


63 


like  the  hat-band  of  a  hat.  To  this  band  are  attached  an  arm 
and  a  pad  with  screw  adjustment.  A  strap  over  the  head  and  one 
beneath  the  chin  prevent  downward  and  upward  displacement. 


^K              ^H 

^^^L        "^HlMWMr           ^K^ 

Fig.  3Q.— Cobb's  splint  applied  to  a  case  of  fracture  of  the  nose.     The  head-band  is  so  adapted 
to  the  shape  of  the  head  that  it  remains  fixed  and  offers  a  point  of  counterpressure. 

Coolidge's  splint  (see  Fig.  40).— This  consists  of  a  tin  pad 
for  the  forehead  with  strap  encircling  the  forehead  for  the  re- 
tention of  the  pad  in  position.  To  the  lower  border  of  the  pad 
are  soldered  two  wire  arms  upon  which  slide  two  small  felt  pads. 
The  arms  can  De  bent  so  that  counterpressure  may  be  obtained 
upon  the  firm  parts  of  the  face,  while  direct  pressure  with  the 
other  pad  is  brought  to  bear  upon  the  nose.  This  splint  is  in- 
expensive and  is  efficient. 

The  nasal  cavity  should  be  cleansed  at  least  twice  daily  with 
antiseptic  douches.  Seller's  tablets,  one  tablet  dissolved  in 
a  quarter  of  a  tumbler  of  warm  water,  used  with  the  Birming- 
ham glass  douche,  make  a  satisfactory  wash.  The  external 
wounds  should  be  dressed  according  to  general  surgical  prin- 
ciples. It  is  well  to  remember  in  this  connection  that  suppurat- 
ing wounds  do  far  better  if  dressed  frequently  than  if  left  to 
accumulate  purulent  discharges. 

After  a  blow  upon  the  nose,  even  if  there  is  no  immediate  de- 
formity, the  nose  should  be  examined  to  determine  the  presence 
of  swelling  upon  the  cartilaginous  septum.  Even  a  slight  blow 
upon  the  nose  may  cause  a  hematoma  of  the  cartilaginous  sep- 


64  FRACTURES    OF    THE    BONES    OF   THE    FACE 

turn.  This  hematoma  is  Hable  to  become  infected  and  to  suppu- 
rate. Considerable  destruction  of  cartilage  may  follow,  resulting 
in  marked  disfigurement  of  the  nose. 

The  involvement  of  the  base  of  the  skull  adds  a  serious  element 
to  an  ordinary  simple  accident  (see  Fig.  15). 


Fig.  40. — Coolidge's  nasal  splint  :   a,  Forehead   plate ;   b,  pad ;   c,  screw  controlling  position  of 

pad ;  d,  head-strap. 

The  prognosis  as  regards  the  resulting  deformity  must  always 
be  guarded.  Union  usually  takes  place  within  two  weeks  of 
the  accident  and  is  firm  in  one  month.  In  treating  fracture 
of  the  nose  it  is  important  to  be  ever  mindful  of  hematoma  of 
the  septum,  and  of  abscess  of  the  septum  resulting  from  the 
hematoma  and  of  deviation  of  the  septum.  The  external  deform- 
ity that  follows  fracture  does  not  tend  to  increase,  but  the  internal 
deformit}'-  does.  It  is,  therefore,  of  importance  to  correct  the  in- 
ternal deformity  as  well  as  the  external.  Unless  the  internal 
deformity  is  corrected,  the  nose  may  be  straight  but  obstructed. 


OLD   FRACTURES    OF    THE    NASAL    BONES 


65 


A  physician  especially  skilled  in  the  care  of  the  nose  should  be 
employed  to  attend  to  the  conditions  existing  inside  the  nose 
following  fracture  of  the  nasal  bones. 

Old  Fractures  of  the  Nasal  Bones. — The  usual  internal  method 
of  employing  a  saw  for  dividing  the  nasal  bones  from  within  the 
nose  and  the  mallet  blow  from  without  is  less  accurate  and  satis- 
factor}^  than  the  direct  external  method  of  Mosher  for  correcting 
the  lateral  deformity  of  the  nasal  bones  following  old  fractures. 

Mosher's  description  of  this  method  is  clear  and  concise,  and 
follows : 


Fig.  41. — A  type  of  a  marked  fracture  of  the  nasal  bones.  The  trauma  was  received  in  the  left 
nasal  bone  primarily.  Note  the  left  bone  depressed,  impacted  with  frontal  and  possibly  with  nasal 
process  of  left  superior  maxilla.  Note  the  right  bone  elevated,  separated  from  its  attachments.  Note 
septum  unattached  in  middle  line  and  deviating  in  lowest  part  to  right  side.  Note  positions  of  thumb 
and  elevating  instrument  (after  Mosher). 


An  incision  one-eighth  inch  long  is  made  in  the  skin  over  the 
lower  outer  angle  of  the  nasal  bone.  A  chisel  to  fit  the  incision 
is  placed  in  it  and  then  driven  through  the  bone  with  a  mallet. 
The  chisel  is  then  pushed  up,  carrying  the  skin  before  it,  and  again 
driven  through  the  outer  border  of  the  nasal  bone.  When  this 
has  been  done  the  third  or  fourth  time  the  top  of  the  nasal  bone 
is  reached.  The  chisel  is  then  turned  horizontally  so  that  it  is 
5 


66 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


parallel  with  the  edges  of  the  teeth  and  at  right  angles  with  the 
incision  through  the  outer  border  of  the  nasal  bone  and  driven  in- 
ward through  the  root  of  the  nasal  bone.  The  operator  is  able  to 
accomplish  this  extensive  chiseling  of  the  bone  through  the  one 
small  skin  incision  because  the  skin  over  the  nasal  bone,  as  one  can 
readily  test  on  himself,  is  displaced  upward  very  readily.  It  can 
be  displaced  downward  but  little.  The  same  procedure  is  repeated 
on  the  other  nasal  bone.  The  horizontal  incision  through  the  root 
of  the  nasal  bone  should  be  especially  thorough,  otherwise  the 


Incision  through  the  root  of  nasal  bone. 


Skin  incision. 

Incision  through  ascend- 
ing process  of  superior 
maxilla. 


Fig.  42. — Dark  line,  skin  incision.     Dotted  lines,  bone  incisions  (Mosher). 

nasal  bones  will  not  be  freed  sufficiently  to  give  good  results. 
This  is  a  point  where  the  internal  method  is  especially  inadequate. 
The  mallet  is  depended  upon  to  fracture  the  root  of  the  nasal 
bone.  The  line  of  the  fracture  which  this  gives  is  not  definite 
and  often  not  free  enough.  Both  of  these  objections  can  be  done 
away  with  by  a  thorough  use  of  the  chisel  in  the  external  method. 
When  the  nasal  bones  are  sufficiently  cut  through  they  are  forced 
into  the  middle  line  by  a  pair  of  septum  forceps  or  by  the  fingers. 
If  they  do  not  start  readily  the  mallet  may  be  used. 

When  the  nasal  bones  have  been  replaced  in  the  middle  line,  it 
will  be  found  in  a  majority  of  cases  that  the  ascending  process  of 
the  superior  maxilla  on  the  side  toward  which  the  bones  originally 
deviated  is  so  prominent  that  it  will  cause  a  marked  deformity  if  it 


FRACTURES  OF  THE  MALAR  BONE  67 

is  left  in  its  present  condition.  This  deformity  is  due  to  the  grow- 
ing together  of  the  displaced  nasal  bone  and  the  ascending  process 
of  the  superior  maxilla.  This  deformity  is  easily  remedied  by 
replacing  the  chisel  in  the  skin  incision,  forcing  the  skin  outward 
as  far  as  is  necessary,  and  then  cutting  off  the  projecting  part  of 
the  ascending  process  with  one  or  two  cuts  of  the  chisel.  Occa- 
sionally the  ascending  process  on  the  other  side  may  require  the 
same  treatment.  It  is  necessary  to  treat  the  ascending  process 
on  both  sides  in  the  case  of  a  wide  nose  which  is  to  be  narrowed. 
The  treatment  of  the  cartilaginous  deviations  within  the  nose 
may  be  primary  at  the  time  of  the  correction  of  the  bony  deformity 
or,  in  certain  intractible  cases,  secondary.  If,  as  Mosher  sug- 
gests, the  packing  necessary  to  maintain  the  connected  septum  in 
good  position  interferes  with  the  replaced  nasal  bones,  causing  their 
displacement,  then  the  secondary  treatment  of  the  septum  after 
the  nasal  bones  have  healed  will  be  best. 

FRACTURES  OF  THE  MALAR  BONE 

Examination. — Palpation  of  the  malar  bone  is  somewhat 
difficult.  The  best  method  of  doing  it  is  to  stand  behind  the 
sitting  patient  (see  Fig.  43),  and  to  feel  both  malar  bones  at 
the  same  time — the  left  one  with  the  left  hand,  the  right 
one  with  the  right  hand.  The  malar  process  of  the  superior 
maxilla  is  felt  inferiorly  by  pushing  the  skin  of  the  cheek  up- 
ward. The  orbital  part  of  this  process  is  felt  superiorly  at  the 
middle  of  the  inferior  border  of  the  orbit.  Following  the  orbital 
margin  outward  and  upward,  the  orbital  border  is  palpated  up 
to  the  frontal  process.  Following  the  malar  process  of  the 
superior  maxilla  backward,  the  free  inferior  border  of  the  malar 
is  felt  continuous  backward  with  the  zygomatic  process.  Start- 
ing on  the  frontal  process,  the  posterior  border  of  the  malar 
may  be  palpated  downward  and  backward  to  the  upper  border 
of  the  zygomatic  process  of  the  temporal  bone.  The  inferior 
surface  of  the  malar  may  be  felt  by  placing  the  fingers,  palm 
upward,  in  the  superior  sulcus  of  the  cheek  and  following  back- 
ward until  the  coronoid  process  of  the  lower  jaw  is  felt.  In 
the  case  of  a  fracture  that  is  as  often  unrecognized  as  is  this 
one  it  is  important  to  be  very  familiar  with  the  details  of  the 
outline  of  the  bone. 


68 


FRACTURES    OF   THE    BONES    OF   THE    FACE 


Symptoms. — Fracture  of  the  malar  bone  is  caused  by  a  severe 
blow  upon  the  cheek.  It  is  rather  unusual  to  find  a  fracture 
of  the  body  of  the  bone.  More  often  there  is  a  fracture  of  one 
of  its  processes,  the  line  of  fracture  being  continuous  with  a 
fracture  of  some  adjoining  bone.  The  malar  is  depressed  as  a 
whole,  or  tilted  inward  toward  the  zygomatic  fossa  because  of  a 
loosening  of  one  or  more  of  its  articulations  or  because  of  a  frac- 


Fig.  43. — Proper  position  from  which  to   palpate  the   malar  bones.     The  fingers   touch  the 
inferior  borders,  the  thumbs  the  posterior  borders,  of  the  malar  bones. 

ture  or  crushing  oi  the  superior  maxilla.  The  deformity  con- 
sists of  a  depression  to  the  outer  side  of  and  below  the  eye.  The 
line  of  fracture  or  separation  can  sometimes  be  palpated. 
Mobility  and  crepitus  are  rarely  obtained.  If  the  depression 
of  the  malar  or  of  an  associated  fracture  of  the  zygomatic  arch 
impinges  upon  the  space  in  which  the  coronoid  process  moves 
in  the  opening  of  the  mouth,  the  motions  of  the  lower  jaw  will 
be  restricted  (see  Fig.  46).  The  limitation  of  motion  of  the 
lower  jaw  may  be  temporary  or  permanent,  depending  upon 
whether  it  is  due  to  hemorrhage  and  swelling  or  bony  pressure. 
The  coronoid  process  of  the  lower  jaw  mav  be  fractured  by 
the  same  force  which  fractured  the  zygoma  or  malar.  Localized 
subconjunctival  hemorrhage  may  appear  if  the  orbit  is  involved. 
If  the  floor  of  the  orbit  is  fractured  so  that  the  infra-orbital 
nerve  is  implicated,  there  will  appear  prickling  sensations  through- 
out the  area  of  distribution  of  that  nerve,  namely,  along  the 
upper  gum,  the  skin  of  the  cheek,  of  the  nose,  and  of  the  upper  Hp ; 
and  there  will  appear  a  subconjunctival  hemorrhage. 


Fig.  44-— Depressed  fracture  of  the  left  malar  bone.    Note  swelling  of  the  left  cheek  and  slight 
hollow  outside  of  left  orbit  (Warren). 


Fi«-  45.— Depressed  left  malar  bone.     Same  case  as  figure  44-     Note  depression  behind  and 
below  left  orbit  (Warren). 


60 


70 


FRACTURES    OF    THE    BONES    OF   THE    FACE 


Treatment. — It  is  sometimes  impossible  completely  to  correct 
the  deformity  except  by  operative  means.  If  any  interference 
with  the  movements  of  the  lower  jaw  persists  after  the  acute 
swelling  disappears, — that  is,  after  two  weeks, — or  if  it  is  very 
evident  at  the  outset  that  the  limitation  of  motion  is  due  to  the 
depression  of  bone,  then  operative  interference  is  demanded. 
Before  a  cutting  operation  is  resorted  to  an  anesthetic  should 
be  administered  and  an  attempt  made  by  pressure  with  a  blunt 


Angle  of 

inferior 

Malar,      maxilla. 


Zygoma. 


Articular  pro- 
cess of  infe- 
rior maxilla. 


Coronoid  pro- 
cess of  infe- 
rior maxilla. 


Fig'  46. — View  of  skull  from  under  surface.  Note  relations  of  coronoid  of  inferior  maxilla  to 
zygomatic  process  and  malar  bones  ;  the  space  on  either  side  of  the  coronoid  process  is  filled  by  mus- 
cle. 

instrument  under  the  malar  from  inside  the  cheek  to  raise  the 
depressed  fragment.  If  this  can  not  be  effected,  a  small  incision 
should  be  made  at  the  most  advantageous  point,  avoiding  mak- 
ing the  fracture  an  open  one.  Through  this  incision  access  is 
gained  directly  to  the  bone.  By  means  of  a  narrow  periosteum 
elevator,  retractor,  hook,  or  a  screw  elevator,  the  fragment  can 
be  raised  into  its  normal  position.  Without  making  any  small  in- 
cision Codman  has  raised  the  depressed  bone  by  grasping  it  securely 
with  a  double  hook  through  the  skin. 

Union  occurs  in  two  weeks.     There  is  no  tendency  to  a  recur- 
rence of  deformity,  therefore  no  retentive  apparatus  is  necessary. 


FRACTURES    OF   THE    SUPERIOR   MAXILLA  7 1 

The  surgeon  is  not  uncommonly  asked  to  remove  the  sHght 
depression  attending  a  healed  fracture  of  the  malar  bone.     This 


Fig.  47 — Fracture  of  the  zygoma.  A  wire  (e)  threaded  to  a  curved  needle  is  passed  under  the 
fragment  that  is  depressed  (x).  Traction  on  this  wire  will  assist  in  elevation  of  the  fragment,  a,  malar  ; 
b,  maxilla  ;  c,  orbit ",  d,  nasal  process  ;  e,  wire  ;  x,  zygoma  and  seat  of  fracture.  The  arrow  points  to 
the  fracture  (after  Matas). 

may  be  most  difficult.  It  should  be  attempted,  however,  as 
in  fresh  injuries,  without  a  cutting  operation,  or  by  an  incision 
within  the  mouth  through  the  mucous  membrane,  or  by  an  opening 
in  the  antrum  and  pressure  outward  with  a  blunt  instrument 
(see  next  section),  or,  if  necessary,  by  an  external  incision. 

FRACTURE  OF  THE  SUPERIOR  MAXILLA 
The  prominent  malar  bone  of  the  cheek  receives  the  direct  blow 
and  transmits  the  force  to  the  delicate  maxilla,  whose  surfaces 
bound  the  antrum  of  Highmore.  Fracture  of  the  superior  maxilla 
occurs  so  frequently  from  a  bicycle  injury  that  it  may  properly 
be  called  the  bicycle  accident.  The  blow  causing  this  fracture 
is  usually  not  in  the  direction  to  damage  the  base  of  the  skull, 
but  to  tear  the  bones  of  the  face.  The  nasal  process  of  the  superior 
maxilla  may  be  broken  when  the  nasal  bone  is  fractured.  The 
anterior  wall  of  the  antrum  may  be  broken  by  the  same  blow. 
The  alveolar  process  may  be  broken.  The  orbital  plate  of 
the  superior  maxilla  may  be  broken.  The  damage  to  the  bones 
of  the  face,  and  particularly  to  the  upper  jaw,  is  associated  with 
injuries  to  various  contiguous  bones.  Blows  result  in  many 
irregularly  disposed  fractures.  The  malar  bone  is  literally 
depressed  into  the  maxilla  and  remains  impacted  in  its  deforming 


72  FRACTURES  OF  THE  BONES  OF  THE  FACE 

position  until  removed.  The  diagnosis  is  made  by  inspecting  the 
mouth,  nose,  and  cheek.     Asymmetry  of  the  face  is  noticeable. 

These  fractures  being  often  open,  there  is  little  difficulty  in 
detecting  them.  A  very  careful  inspection  should  be  made, 
with  an  anesthetic  if  necessary,  to  determine  the  extent  of  the 
lesions.  A  slight  hemorrhage  immediately  after  the  accident 
from  the  nose  suggests  an  injury  to  the  mucous  membrane  of 
the  antrum.  Emphysema  and  great  swelling  of  the  face  occur. 
There  may  be  no  wound  of  the  skin.  Whether  the  injury  to 
the  upper  jaw  is  associated  with  injury  to  the  base  of  the  skull 
or  not  can  be  determined  in  the  absence  of  visible  signs  by  the 
subsequent  development  of  cerebral  symptoms.  Necrosis  of 
bits  of  bone  is  rare  after  upper-jaw  fractures,  excepting  fracture 
of  the  alveolar  border.  Hemorrhage  may  be  considerable,  but 
it  is  easilv  controlled  by  pressure.  The  infraorbital  nerve  may 
be  damaged,  and  this  is  indicated  by  anesthesia  in  its  distribu- 
tion. The  lachrymal  canal  may  be  temporarily  compressed 
or  obliterated. 

Treatment. — If  there  is  no  wound  of  the  skin  and  much 
depression  of  the  jaw,  so  that  the  face  is  knocked  in,  it  will  be 
necessary  to  devise  some  m.ethod  of  elevating  the  depressed 
bone  and  of  restoring  the  normal  contour  of  the  face.  To  avoid 
a  visible  scar,  the  mucous  membrane  should  be  incised  on  the 
inner  side  of  the  upper  lip,  and  an  attempt  made  to  elevate  the 
fragments  by  an  instrument  introduced  through  the  incision. 
As  little  bone  as  possible  should  be  removed,  so  as  to  leave 
sufficient  support  to  the  soft  parts  of  the  cheek  after  healing. 
Only  thus  can  a  falling  in  of  the  cheek  be  prevented. 

If  access  through  the  mouth  is  unsuccessful,  the  antrum  should 
be  opened  and  intra-antral  pressure  made.  Incision  of  the 
skin  for  reduction  is  to  be  avoided  if  possible.  If  it  is 
found  necessary  to  introduce  a  curved  blunt  instrument,  a 
urethral  sound,  into  the  outer  corner  of  the  antrum,  itself  and 
to  raise  the  depressed  malar  by  carefully  applied  pressure  from 
within  outward,  the  method  suggested  by  Lothrop  should  be 
employed.  Access  to  the  antrum  is  best  obtained  by  incising 
the  mucous  membrane  in  the  upper  part  of  the  canine  fossa. 
The  antrum    should    be  carefully  packed  with   narrow  strips   of 


TREATMENT  73 

gauze  to  maintain  the  position  of  the  fracture  and  to  insure 
drainage  of  the  antrum.  The  gauze  should  be  left  in  situ  for 
four  or  five  days  and  then  be  carefully  removed. 

The  accidental  wounds  should  be  thoroughly  and  vigorously 
swabbed  with  a  solution  of  corrosive  sublimate  (i  :  5000).  The  use 
of  tiny  swabs  of  gauze  held  by  forceps  will  facilitate  this  procedure. 
The  avoidance  of  sepsis  in  these  cases  is  of  paramount  importance. 
If  the  wounds  become  septic,  there  is  great  danger  of  an  exten- 
sion of  the  inflammatory  process  to  the  deeper  parts  or  even 
to  the  meninges  of  the  brain.  Lacerations  of  the  soft  parts — 
lips  and  cheeks — may  have  their  edges  approximated  to  secure 
less  scar  than  if  left  unsutured.  Loose  small  bits  of  bone  should 
be  removed  with  forceps  and  scissors.  Loosened  teeth  should 
be  left  in  good  position  in  their  sockets.  A  mold  of  the  lower 
jaw  should  be  taken  in  composition  or  plaster-of-Paris,  if  pos- 
sible, by  a  competent  dentist,  and  a  rubber  splint  made  from 
this  mold  to  fit  the  teeth  and  alveolar  border  of  the  lower  jaw. 
When  this  splint  is  applied,  its  upper  surface  may  be  brought 
up  against  the  teeth  of  the  upper  jaw  and  held  snugly  in  ap- 
position by  an  external  bandage,  as  in  fracture  of  the  lower 
jaw.  This  splint  will  materially  assist  in  reducing  the  displace- 
ment of  the  upper-jaw  fragments.  It  may  be  possible  for  a 
dentist  to  apply  a  splint  directly  to  the  alveolar  margin  and 
teeth  of  the  upper  jaw.  If  this  is  possible,  greater  security  of 
fragments  will  be  obtained  than  by  any  other  method  of  treat- 
ment. The  physician  may  greatly  assist  in  immobilizing  the 
fracture,  until  a  permanent  dressing  is  applied,  by  making  quickly 
a  temporary  splint  of  dental  wax  or  dental  composition,  and 
applying  it  to  the  teeth  and  alveolar  margin  of  the  upper  jaw. 
This  composition  is  softened  and  made  malleable  by  placing 
it  in  hot  water;  it  can  then  be  molded  on  the  jaw,  and  in  two 
or  three  minutes  is  firm  (see  Fracture  of  the  Lower  Jaw). 

After  Care. — Six  weeks  to  two  months  will  be  necessary  to 
insure  firm  union  and  freedom  from  complications.  The  swell- 
ing associated  with  the  reparative  process  will  gradually  sub- 
side. Great  care  must  be  exercised  in  the  nursing  of  the  patient 
after  this  injury,  as  the  element  of  shock  is  an  important  one 
to  be  considered.  Strychnin  sulphate  (g-y-  of  a  grain),  given  two 
or  three  times  daily,  is  indicated  if  there  is  evidence  of  shock 


74         FRACTURES  OF  THE  BONES  OF  THE  FACE 

following  the  accident.  This  should  be  continued  each  day  for 
as  long  a   period   as  shock  is  evident. 

Proper  nourishment  under  these  adverse  conditions  of  ad- 
ministration is  to  be  given  careful  consideration.  lyiquids 
alone  are  to  be  used  the  first  week.  These  may  be  given  by  en- 
emata  or  by  the  mouth  with  a  tube  to  the  back  of  the  pharynx 
or  by  a  nasal  tube  if  necessary.  Nasal  feeding  is  simply  and 
easily  carried  out.  A  rubber  tube  three  feet  long  is  needed,  to 
one  end  of  which  is  attached  a  funnel  and  to  the  other  end  a  soft- 
rubber  catheter,  in  size  No.  lo  F.  The  patient  is  half  reclining 
while  the  surgeon  introduces  the  catheter  into  the  nose  until 
it  passes  well  back  and  down  into  the  pharynx.  The  funnel, 
somewhat  elevated  a  foot  or  more  above  the  patient's  head,  is 
kept  filled  with  the  liquid  nourishment  so  that  its  contents  run 
slowly  into  the  esophagus.  A  plug  of  absorbent  cotton,  moistened 
with  a  four  per  cent,  cocain  solution,  and  placed  in  the  nose  for 
a  few  minutes  before  feeding,  facilitates  this  procedure. 

The  nose  and  mouth  should  be  douched  and  swabbed  reg- 
ularly. This  should  be  done  after  feeding  the  patient,  and  as 
often  as  every  four  hours,  in  order  to  avoid  all  odor  from  the 
mouth.  Alkalol,  two  teaspoonfuls  to  half  a  cup  of  water,  is  a 
satisfactory  wash  for  this  purpose.  If  the  intra-antral  method 
of  Lothrop  has  been  employed  the  antrum  for  the  first  few  days 
should  be  irrigated  gently  with  warm  saline  solution.  The 
profuse  dribbling  of  saliva  which  attends  this  fracture  demands 
drainage  of  the  mouth  by  wicks  of  gauze  placed  in  the  cheeks 
and  gauze  handkerchiefs  for  keeping  the  surrounding  parts  dry. 
Wiring  the  fragments  of  bone  may  be  necessary  if  there  is 
great  displacement,  but  is  to  be  avoided  if  possible.  Wiring  the 
alveolar  border  to  the  body  of  the  jaw  may  be  demanded.  Suture 
of  the  bony  fragments  with  chromicized  catgut  will  often  steady 
them  in  position  until  union  takes  place. 

FRACTURES  OF  THE  INFERIOR  MAXILLA 

With  the  exception  of  the  superior  internal  surface  of  the  artic- 
ular process,  practically  the  whole  of  the  inferior  maxilla  may 
be  palpated.     Fractures  of  the  inferior  maxilla  are  caused  by 


FRACTURES    OF    THEJ    INFERIOR   MAXILLA 


75 


direct  violence.     The  seat  of   the   fracture   will   be  determined 
by  the  force  and  direction  of  the  blow,  by  the  location  of  the 


Fig.  48.— Fracture  of  the  inferior  maxilla  Fig.  49-— Fracture  of  the  inferior  maxilla 

(interdental  splint)  (X-ray  tracing).  in  two  places.     Alinement    of    teeth    perfect 

(X-ray  tracing). 

teeth  in  the  jaw  (the  jaw  being  weakest  where  the  teeth  have 
been  lost),  by  the  presence  of  any  foreign  body  between  the  teeth 
(such  as  a  pipe),  and  by  the  presence   or  absence  of  muscular 


Fig.  so.— Fracture  of  lower  jaw.     Xotc  the  Inss  of  alignment  of  teeth  of  lower  jaw. 

relaxation.     Fractures  of  the  base  of  the  skull  through  blows  on 
the  jaw  are  more  likely  to  occur  if   the  mouth  is  open.     Frac- 


76 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


tures  of  the  body  of  the  bone  are  com- 
mon; of  the  ramus  behind  the  molar 
teeth,  rather  uncommon;  of  the  con- 
dyloid and  coronoid  processes,  very 
uncommon.  The  seats  of  fracture  of 
the  inferior  maxilla  are  shown  in  the 
accompanying  illustrations  (see  Figs. 
48-52). 

Excepting  those  of  the  condyloid 
and  coronoid  processes,  fractures  of 
the  inferior  maxilla  almost  always 
open  into  the  mouth.  They  occasion- 
ally open  through  both  the  mucous 
membrane  and  the  skin. 

Examination. — Even  when  the 
patient  can  not  open  the  mouth  suffi- 
ciently to  admit  the  examining  finger, 
palpation  of  the  body  and  ramus  of  the 
jaw,  with  one  finger  in  the  cheek  and 


Fig.  52. — Fracture  of  the  lower  jaw,  showing  loss  of  aline- 
ment  of  teeth. 


Fig.  51. — Fracture  of  the  inner 
side  of  the  alveolar  process,  from 
a  force  applied  to  teeth. 


another  finger  upon 
the  chin,  will  often  re- 
veal the  seat  of  frac- 
ture. 

Symptoms. —  Pain, 
crepitus,  and  abnor- 
mal mobility  may  be 
present.  Immediate 
swelling  of  the  gum 
appears  at  the  seat  of 
the  fracture.  Teeth 
contiguous  to  the  frac- 
ture of  the  body  of  the 
maxilla  will  be  either 
displaced  or  loosened. 
The  displacement  of 
the  fragments  in  frac- 
ture of  the  body  and 
ramus    will    be    most 


TREATMENT 


77 


easily  detected  by  noticing  the  differences  in  level  of  the  teeth  on 
each  side  of  the  fracture  (see  Fig.  52J.  The  face  appears  swollen. 
After  a  few  days  the  submaxillary  and  adjoining  cervical 
lymphatic  glands  become  enlarged.  The  salivary  secretions 
are  increased  in  quantity,  and  because  of  the  disinclination  to 
painful  swallowing,  the  saliva  dribbles  out  of  the  mouth. 
If  the  fracture  opens  into  the  mouth,  suppuration  often  ap- 
pears and  pus  mingles  with  the  saliva.  Particles  of  decom- 
posing food  between  the  teeth  and  in  the  spaces  outside  the  jaw 
within  the  cheeks  add  to  the  bacterial  pabulum.     The  odor  from 


Fig.  53- — Aluminium  splint  to  be  placed  on  teeth.     For  closed  fracture,  a  continuous  capping 
of  gold  or  aluminium  or  other  metal  cemented  upon  the  teeth. 


this  mass  of  foul  material  is  characteristically  penetrating  and 
offensive.  After  a  few  weeks  necrosis  of  bone  may  occur  at 
the  seat  of  fracture,  with  abscess  formation.  A  discharging 
sinus  pointing  to  the  disease  appears.  These  cervical  abscesses, 
often  difficult  to  manage,  occupy  the  region  of  the  body  of  the 
jaw.  The  submaxillary  and  upper  carotid  triangles  may  be 
filled  by  a  brawny  infiltration  associated  with  necrosis  of  a  frac- 
tured jaw.  On  the  other  hand,  with  proper  treatment  and  in 
less  difficult  cases  the  course  of  the  healing  process  is  simple 
and  of  easy  management.  Suppuration  is  prevented.  There  is 
no  necrosis,  and  the  repair  of  the  fracture  takes  place  unhindered. 
Treatment. — The  primary  object  of   treatment    is   the    pres- 


78  FRACTURES  OF  THE  BONES  OF  THE  FACE 

ervation  of  the  natural  alinement  of  the  teeth.  This  object 
is  attained  by  a  complete  reduction  of  the  fragments  of  the 
fractured  bone.  If  a  tooth  interferes  with  the  perfectly  accurate 
closure  of  the  mouth,  and  if  the  adjustment  of  the  fragments 
is  prevented  by  the  position  of  the  tooth,  it  should  be  extracted 
at  once.  Ordinarily,  there  is  but  slight  displacement.  This 
displacement  can  be  corrected  by  digital  pressure  upon  both 
fragments.  Having  reduced  the  fracture  it  is  most  important  "to 
make  the  reduction  secure,  to  hold  the  fragments  in  proper  position. 
Fracture  of  the  Body  of  the  Jaw. — The  simple  fracture  of  the 


Fig.  54. — Four-tailed  bandage  lor  iractured  jaw. 

body  of  the  jaw  without  much  displacement  may  be  tempor- 
arily treated  by  the  four-tailed  bandage,  which  should  hold 
the  teeth  of  the  lower  jaw  closely  in  apposition  with  the  corre- 
sponding teeth  of  the  unbroken  upper  jaw.  As  soon  as  practic- 
able, a  dental  splint  of  rubber  or  aluminium  should  be  made 
and  applied  by  a  dentist.  This  aluminium  splint  fits  the  crowns 
of  the  teeth  some  distance  upon  each  side  of  the  fracture,  and 
holds  the  fragments  firmly  in  apposition  (see  Fig.  53).  It  also 
permits  of  opening  and  shutting  the  mouth.  The  old-time 
four-tailed  bandage  and  extradental  splint  of  millboard  (see 
I'^ig-   54)  ^s  inefficient.     As  a  permanent  dressing  it  should  be 


FRACTURE  OF  THE  BODY  OF  THE  JAW 


79 


discarded.  It  is  useful  only  as  a  temporary  support.  In  the 
simple  cases,  in  the  absence  of  a  competent  dentist  to  make  the 
aluminium  or  rubber  dental  splint,  a  splint  of  silver  wire  passed 
around  many  teeth  upon  each  side  of  the  seat  of  fracture  is  often 
efficient.     The  method  of  wiring  two  adjoining  teeth,  those  on 


|^T*yc#  'f 


Fig.  55.— Fracture  of  the  lower  jaw.     Wiring  with  silver  wire. 


Pig.  56.— Hard-rubber  splint,  with  arms  and  posterior  strap. 

each  side  the  fracture,  is  unsatisfactory  in  that  the  strain  loosens 
the  teeth  and  displacement  is  easily  effected   (see  Fig.  55)- 

The  method  of  wiring  together  corresponding  teeth  in  the 
upper  and  lower  jaws  on  each  side  of  the  fracture,  so  closing  the 
mouth,  may  secure  accurate  alinement  in  certain  carefully  chosen 


8o 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


cases.     The   same  objection  applies  to  this  method  as  to  that 
just  previously  stated. 


Fig.  57. — Hard-rubber  splint,  with  arms  and  bandage  applied.    Similar  to  Fig.  56(Moriarty). 


A 

^fe 

X 

i 

^Ov 

1 

^P 

fc£^\ 

11 

Fig.  5S. — :Hard-rubber  splint;  wire  arms  and  chin-piece  held  together  by  metal  rods  and  nuts. 


It  may  be  wise,  if  it  is  impracticable  to  have  an  inter- 
dental splint  made,  to  suture  the  fragments  together  after 
drilling    holes    through    the    bones.       If    silver  wire    suture    is 


Fracture;  op  the;  body  of  the;  jaw  8i 


Fig-  59- — Same  splint  as  seen  in  figure  58;  superior  view. 


FiR.  Oo.    .Front  view  of  splint  (figure  58)  with  mouth  closed  (Moriarty). 


82 


Fractures  oif  thk  bones  op  the  face 


Fig.  6i. — Side  view  of  splint  (figure  ss) ;   arms  and  chin-piece  in  position  (Moriarty). 


f. 

-N 

f- 

^      1 

1^^^^ 

«fe 

Fig.  62. — Splint  similar  to  figure  58.     Mouth  maybe  opened  without  impairing  efficiency  of 

splint  (Moriarty). 


Treatment 


83 


used,  it  may  be  removed  as  soon  as  union  is  secured.  If 
there  are  objections  to  the  silver  wire,  one  may  use  chromic 
catgut,  several  strands  being  strong  enough  to  hold  firmly  for 
a   sufficient   time. 

Fracture  of  the  body  toward  the  angle  of  the  jaw,  through  the 
region  of  the  molar  teeth,  is  often  less  easily  held  in  good  position. 
To  the  dental  rubber  sphnt  the  dentist  should  add  lateral  arms  of 
wire,  held  in  position  by  a  posterior  strap  (see  Fig.  56).  These 
wire  arms  increase  the  efficiency  of  the  dental  splint,  for  a  ban- 
dage is  passed  under  the  chin  between  the  wires  and  thus  steadies 
the  jaw  by  upward  pressure  (see  Fig.  57).  If  a  still  more  efficient 
method  is  demanded,  the  dentist  uses  an  extradental  chin-piece 


Fig.  63. — Modeling  cups.     No.  22J  is  used  for  the  upper  jaw  and  No.  25  for  the  lower  jaw. 


of  metal  (see  Fig.  58).  which  is  adjusted  by  screws  so  that  firm, 
evenly  graduated  pressure  upon  the  fractured  jaw  is  maintained 
between  the  inside  dental  spHnt  and  the  outside  chin-piece. 
While  wearing  the  sphnt  the  mouth  can  be  opened  easily  (see 
Figs.   60,  61,  62). 

The  Making  of  the  Dental  Splint. — If  an  impression  is  desired 
of  the  crowns  of  the  teeth  and  the  adjoining  gum,  it  is  best  made 
by  using  the  modeling  composition  manufactured  for  the  use  of 
dentists.  The  necessary  amount  of  the  composition  is  dropped 
into  hot  water;  when  soft,  the  composition  is  put  into  the  metal 


Fig.  64. — Plaster  cast  of  fracture  of  the 
jaw. 


Fig.  65. — Plaster  cast  of  lower  jaw  articu 
lating  with  upper  jaw. 


Fig  66. — Simple  vulcanite  splint,  with  boxes  vulcanized  on  each  side  (Moriarty)i 


Fig.  67. — Hard-rubber  splint  in  position,  upper  teeth  resting  upon  it  (Moriarty). 


TREATMENT 


85 


impression-cups  (see  Fig.  63).  The  surface  of  the  composition  is 
warmed  by  holding  it  over  a  flame  or  holding  it  again  in  hot  water; 
then  the  impression-cup  containing  the  softened  composition  is 
placed  in  the  mouth  and  the  impression  made.  Immediately  upon 
the  removal  of  the  mold  from  the  mouth  the  composition  cools  and 
hardens.  From  this  mold  is  made  the  dupHcate  of  the  alveolar 
border  and  the  teeth  in  plaster-of- Paris  (see  Fig.  64).  The 
lines  of  fracture  are  clearly  indicated  upon  the  plaster  cast.  With 
a  fine  saw  the  cast  is  cut  upon  these  lines  and  the  lower  teeth  are 
articulated  with  the  plaster  cast  of  the  upper  jaw,  which  has  been 


Fig.  68. — Interdental  splint  used  in  fracture  of  the  jaw  when  no  teeth  exist  in  upper  alveolar 

arch  (after  Moriarty). 


made.  Plaster  cream  is  used  to  hold  the  sawed  portions  to- 
gether. In  other  words,  the  fracture  has  been  reproduced  and 
reduced  in  plaster-of- Paris.  Both  upper  and  lower  casts  are  then 
put  upon  an  articulator  (see.  Fig.  65) .  A  vulcanite  splint  is  made 
from  this  reconstructed  lower  jaw,  and  when  this  is  applied  to  the 
fractured  jaw  as  an  interdental  splint,  the  deformity  is  corrected 
and  comfortably  prevented  from  recurring  (see  Figs.  66,  67). 

Fracture  of  the  Ramus  of  the  Inferior  Maxilla  Just  Behind  the 
Molar  Teeth. — The  displacement  is  difficult  to  correct.  The  frac- 
ture is  usually  oblique  from  before  backward  and  downward,  as 
seen  in  the  tracing  (see  Fig.  49).  The  body  of  the  jaw  drops 
downward  and  backward  and  the  ramus  slides  forward.     No  den- 


86  FRACTURES  OF  THE  BONES  OF  THE  FACE 

tal  splint  is  practicable,  because  there  are  no  teeth  on  one  side  of 
the  fracture  to  which  the  splint  could  be  attached.  Etherization 
will  often  be  found  helpful,  and  at  times  necessary,  in  the  reduc- 
tion of  this  deformity.  Reduction  is  accomplished  by  pressure 
backward  upon  the  ramus  with  the  thumb  in  the  mouth  and  a 
simultaneous  lifting  forward  and  upward  of  the  body  of  the  jaw. 
Reduction  is  maintained  by  an  outside  pad  and  metal  chin-piece 
and  a  buckle  and  strap  splint.  This  buckle  and  strap  splint  (see 
Fig.  69).  is  of  great  advantage  because  it  is  easily  adjusted,  and 
the  amount  of  pressure  can  be  graduated.  It  is  of  importance  to 
note  here  that  even  after  this  fracture  has  been  reduced  and  is  at 
the  outset  apparently  held  reduced  by  the  bandage,  yet  it  will 


Fig.  69. — Molded  leather  chin-piece  with  buckles  and  straps  for  graduated  pressure  upon 
a  fracture  of  the  inferior  maxilla  (after  Moriarty). 

usually  slump  away  a  little  and  at  the  end  of  the  first  twenty-four 
hours  after  setting  the  fracture  the  fragments  will  be  found  to  be 
partially  unreduced.  Upon  a  second  application  of  pressure  by 
tightening  the  bandage  the  fragments  will  come  into  apposition 
with  comparative  ease.  By  careful  and  repeated  adjustments  of 
the  bandage  and  padding,  after  a  week  and  a  half  even  in  the 
most  obstinate  cases,  the  jaw  will  be  found  to  be  in  good  position, 
with  the  teeth  articulating. 

Fracture  of  the  Body  of  the  Ramus  upon  the  Same  or  Opposite 
Sides  of  the  Inferior  Maxilla. — The  fracture  is  difficult  to  hold 
fixed.     In  this  case  the  dental  aluminium  or  rubber  splint  will  be 


TREATMENT 


87 


needed,  together  with  the  outside   pressure  made  by  the  metal 
chin- piece. 

Whichever  method  of  treatment  is  adopted,  the  fracture  at 
first  should  be  inspected  daily  in  order  to  insure  accurate  adjust- 
ment of  apparatus.  The  mouth  and  teeth  should  be  kept  scrup- 
ulously clean.  When  practicable,  the  teeth  should  be  scaled  by  a 
dentist  before  permanent  apparatus  is  applied.  Brush  and  swab 
with  some  mild  antiseptic  wash,  such  as  Listerin,  one  part  in  four 
of  water,  should  be  used  after  taking  nourishment  and  before  bed- 
time and  upon  rising  in  the  morning.  The  liquid  nourishment  of 
the  patient  should  be  given  through  a  glass  tube  at  first.  If  it  is 
unwise  to  open  the  mouth,  a  rubber  catheter  may  be  used  behind 


Fig.  70. — If  no  lower  teeth  exist,  the  artificial  teeth  may  be  utilized,  as  seen  above,  as  a 
splint.  Boxes  seen  on  sides  of  plate,  to  which  arms  and  chin-pieces  can  be  attached  (after 
Moriarty). 

the  molar  teeth.  The  rubber  catheter  with  a  siphon  attached  is  a 
very  satisfactory  method  of  feeding.  The  general  health  should 
receive  careful  attention.  A  patient  with  this  fracture  is  apt  to 
become  despondent  and  anxious  about  himself,  particularly  if 
suppuration  exists.  The  repeated  swallowing  of  foul  secretions 
impairs  the  appetite,  causes  indigestion  and  generally  poor  health. 
The  loss  of  variety  in  diet  favors  this  condition.  Out-of-door 
exercise,  plenty  of  sleep,  a  mild  tonic,  such  as  ferrated  elixir  cali- 
sayae  and  sulphate  of  strychnin,  and  a  little  wine,  will  all  assist 
in  restoring  and  maintaining  good  health. 

Abscesses  which  appear  should  be  treated  by  incision,  evacua- 
tion of  their  contents,  drainage,  and  antiseptic  dressings.     Bits 


Fig.  71- — Matas'  adjustable  metallic  splint  for  fracture  of  the  lower  jaw  (latest  model).  The 
splint  consists  of  the  following  detachable  parts  :  (a)  a  mouth-piece  of  soft  metal  (block  tin) ;  (b)  a 
clamp  adjusted  and  tightened  with  a  screw  :  (c)  a  chin-plate  (of  perforated  aluminum),  which  can  be 
moved  backward  or  forward  by  sliding  on  the  lower  limb  of  the  clamp.  This  is  fi.xed  and  held  in 
place  by  a  thumb-screw. 


Fig.    72. — Lateral  view  of  the  Matas  splint  in  situ,  as  shown  on  adult  skull. 


Fig.  73. — Front  view  of  fig.  72. 


Fig.  74.  J.  H.,  compound  fracture  of  lower  jaw,  caused  by  list  blow.  Line  of  fracture  oblique 
bisecting  lower  jaw  at  angle  and  terminating  above  behind  last  molar  tooth.  Great  displacement  and 
mobility  of  fragments.  Reduction  and  apposition  only  obtained  by  splint.  Barton  bandage  used  to 
immobilize  jaws  with  the  splint.    Splint  worn  eighteen  days,  and  followed  by  excellent  results  (Matas). 


90 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


of  necrosed  bone  should  be  removed.  Union  in  fracture  of  the 
jaw  occurs  ordinarily  in  from  three  to  five  v/eeks.  The  apparatus 
is  to  be  worn  until  the  union  of  the  fracture  is  firm. 

Fracture  of  the  coronoid  and  articular  processes  is  to  be  treated 
by  simple  immobilization  of  the  jaw. 

These  various  methods  of  immobilization  mentioned  may  fail 
in  some  unusual  fractures ;  if  so,  suturing  of  the  fracture  through 
the  bone  with  silver  wire  or  other  material  should  be  undertaken. 


Fig.  75- — Fracture  of  the  condylar  process  of  the  lower  jaw. 

forward. 


Note  the   displacement  of  the  jaw 


The  Matas  Splint. — The  Matas  splint  is  of  value  in  a  hospital 
clinic.  It  is  adapted  to  the  majority  of  the  common  fractures 
of  the  jaw,  particularlv  in  men.  It  is  useful  while  displacement 
is  continually  recurring.  It  is  applicable  to  fractures  of  the 
body  of  the  jaw.  The  accompanying  figures  illustrate  its  con- 
struction and  application.  The  splint  is  on  the  principle  of  a 
clamp,  one  arm  holding  the  mouthpiece,  the  other  the  chin-cup. 
The  mouthpiece  and  chin-plate  are  both  detachable  and  adjust- 
able from  the  clamp  itself  (see  Figs.  71,  72,  73,  74). 


CHAPTER  III 

FRACTURES  OF  THE  VERTEBRAE 

Anatomy. — The  forked  spine  of  the  axis  may  be  felt  beneath 
the  occiput  upon  deep  pressure.  The  spines  of  the  third,  fourth, 
and  fifth  cervical  vertebrae  recede  from  the  surface,  and  can  not 
be  felt  distinctly.     The  spines  of  the  sixth  and  seventh  vertebrae 


Fig.  76. — Fracture  of  the  body  of  the  first  lumbar  vertebra.     Arnnv  ijoints  to  vertebral  body.     Note  the 
displacement  of  the  two  fragments. 

project  distinctly,  and  can  be  palpated.  At  the  bottom  of  the 
furrow  in  the  middle  line  of  the  back  are  felt  the  spines  of  the 
dorsal  and  lumbar  vertebrae.  The  spinous  processes  from  the 
seventh  cervical  to  the  third  sacral  are  rather  easily  palpated. 

91 


92 


FRACTURES  OF  THE  VERTEBRA 


The  spinal  cord  extends  from  the  lower  edge  of  the  foramen  mag- 
num to  the  lower  border  of  the  body  of  the  first  lumbar  vertebra. 
The  phrenic  nerve  leaves  the  spinal  canal  between  the  third  and 
fourth  cervical  vertebrae.  By  palpation  through  the  mouth  the 
bodies  of  the  vertebrae  may  be  felt  down  to  about  the  upper  border 
of  the  body  of  the  fifth  vertebra.  The  cervical  enlargement  of  the 
spinal  cord  is  more  marked  than  the  lumbar.  It  commences  at 
the  third  cervical  vertebra  and  ends  at  the  second  dorsal  vertebra. 
The  lumbar  enlargement  commences  at  the  level  of  the  ninth 
dorsal  vertebra  and  reaches  to  the  twelfth  dorsal  vertebra.  The 
spinal  cord  is  well  protected  from  injury. 


Fig.  7>'. — Diagram  of  a  vertebra  and  spinal  cord  in  liorizontal  section.  Note  that  the  cord 
is  suspended  within  the  bony  canal.  Note  the  great  space  between  the  cord  and  bony  wall. 
Note  that  the  cord  is  well  protected  against  trauma. 

The  vertebrae  commonly  fractured  are  the  fourth,  fifth,  and 
sixth  cervical,  the  twelfth  dorsal,  and  the  first  lumbar.  The  in- 
jury to  the  vertebrae  is  caused  in  one  of  three  ways:  by  a  direct 
blow,  fracturing  the  arches ;  by  a  fall  upon  either  the  head  or  the 
buttocks,  crushing  the  bodies  of  the  vertebrae ;  or  by  forced  flexion 
or  extension  of  the  spine,  causing  a  dislocation  with  or  without 
fracture  of  the  bodies  and  articular  processes.  More  than  one- 
half  of  the  fractures  of  the  cervical  vertebrae  are  fractures  of  the 
spinous  processes.  More  than  two-thirds  of  the  cases  of  fracture 
of  the  dorsolumbar  vertebrae  are  fractures  of  the  bodies  of  those 
vertebrae.  A  dislocation  without  fracture  may  occur  in  the  cervi- 
cal region ;  it  is  rare  in  other  regions  of  the  spine. 


ANATOMY 


93 


It  is  important  in  localizing  spinal-cord  lesions  to  know  the 
point  at  which  each  nerve  arises  from  the  spinal  cord,  because  the 
point  of  origin  does  not  correspond  with  that  at  which  the  nerve 
emerges  from  the  spinal  canal.  The  point  of  origin  is  higher  than 
the  point  of  exit.  Many  of  the  nerves  pass  obliquely  from  the 
cord,  lying  still  within  the  vertebral  canal  after  leaving  the  cord. 


TABLE  STATING  LESIONS  FOLLOWING  INJURY  TO  DEFINITE 
VERTEBRAE. 


Spinal 
Segments. 


Muscles   Involved. 


Vertebra 
Dislocated. 


Reflexes  In- 
volved. 


Cervical : 

First,    second, 

third     .    .    .  [Death].  Skull  on  atlas,  atlas  on 

axis. 

Fourth     .    .    .  Diaphragm.  Axis  on  third  cervical 

Fifth    ....  Biceps,  supinators,  deltoid.  Third  on  fourth. 

Sixth    ....  Pronators,  triceps.  Fourth  on  fifth. 

Seventh   .    .    .  Extensors,  flexors  of  wrist.  Fifth  on  sixth. 
Eighth  and  first 

dorsal  .    .    .  Intrinsic  muscles  of  hand.  Sixth  on  seventh. 


Pupil  is  small 
and  reaction 

sluggish. 


Dorsal  : 

Secon 

d 

to 

twelfth 

.    .  Intercostal  and  abdominal 

Lumbar  : 

muscles  (trunk). 

Second 

.    .  Cremaster. 

Third 
.    Fourth 

Fiftli 

1 

Adductors. 
Outward  rotators. 

Extensors  of  thigh,  flexors 
of  knee. 

Sacral  : 

First     . 

.    .  Extensors  of  foot. 

Second 

Calf  muscles. 

Third, 

foi 

irth. 

fifth 

.    .  Perineal  muscles. 

Epigastric,  ab- 
dominal. 

Eleventh     on     twelfth    Cremasteric, 
dorsal. 


_,      ,r,         ,-      ,       ,  Gluteal. 

1  weiith  on  first  lumbar.  . 

Knee-jerk. 


First  on  second  lumbar.  Plantar  and 
ankle  -clo- 
nus. 


These  nerves  within  the  canal  are  liable  to  pressure  from  the 
vertebral  fracture.  For  example,  a  fracture  of  the  eleventh 
dorsal  vertebra  would  injure  not  only  the  cord  at  this  level,  but 
in  addition  might  injure  the  last  dorsal  and  upper  lumbar  nerves. 
The  lower  the  spinal  nerves  arise,  the  longer  is  their  intraspinal 
course.     The  points  of  origin  of  the  spinal  nerves  from  the  cord 


94  Fractures  of  the  vertebra 

with  reference  to  the  spines  of  the  vertebrae  are  as  follows  (see 
Fig.  78) :  The  eight  cervical  nerves  arise  from  the  cord  between 
the  occiput  and  the  sixth  cervical  spine.  The  upper  six  thoracic 
nerves  arise  from  the  cord  between  the  sixth  cervical  spine  and 
the  fourth  dorsal  spine.  The  lower  six  thoracic  nerves  arise 
from  the  cord  between  the  fourth  and  tenth  dorsal  spines.  The 
five  lumbar  nerves  arise  from  the  cord  opposite  to  the  eleventh 
and  twelfth  dorsal  spines.  The  five  sacral  nerves  arise  from  the 
cord  opposite  to  the  first  lumbar  spine.  No  hard-and-fast  rule 
at  present  is  applicable  to  ths  enumeration  of  the  lesions  following 
fractures  and  dislocations  of  definite  vertebrae.  From  the  com- 
bined experience  of  such  clinicians  as  Gowers,  Thorburn,  Kocher, 
Putnam,  Dennis,  Walton,  Bullard,  Thomas,  and  others  the  pre- 
ceding table  (p.  93)  is  constructed,  and  is  valuable  for  practical  use. 

Examination  of  an  Injury  to  the  Spine. — Four  questions 
are  to  be  answered :  What  was  the  nature  of  the  accident?  What 
does  palpation  of  the  spine  reveal  as  to  the  nature  of  the  lesion? 
What  is  the  level  of  the  lesion?     Is  the  lesion  partial  or  complete? 

General  Symptoms  Common  to  Fractures  of  the  Vertebrae. 
— Signs  of  shock  will.be  present.  At  the  seat  of  the  bony  lesion 
will  be  found  pain,  tenderness,  abnormal  mobility  and  sometimes 
crepitus  and  deformity.  The  deformity  will  ordinarily  be  a  back- 
ward bending,  or  kyphosis,  of  the  spinal  column  at  the  seat  of 
fracture,  unless  there  exists  a  unilateral  dislocation,  when  the 
deformity  will  be  irregular  in  appearance  the  chief  symptoms 
depend  upon  the  injury  done  to  the  spinal  cord.  In  general  it 
may  be  stated  that  motor  and  sensory  paralysis,  either  partial  or 
complete,  will  be  found  up  to  the  level  of  the  lesion.  The  reflexes 
are  ordinarily  below  the  lesion,  wanting  at  first  and  increased  later. 
If  a  complete  lesion  is  present  the  reflexes  will  be  entirelv  wanting. 

There  may  be  temporary  suppression  of  urine  (Wagner).  In 
lower  thoracic  fracture  hematuria  is  sometimes  met  with  inde- 
pendently of  direct  damage  to  the  kidney  substance.  Retention 
and,  later,  incontinence  of  urine  and  feces  will  exist.  Cystitis 
of  the  urinary  bladder  will  develop  at  an  early  date.  Bed-sores 
and  great  sloughing  areas  of  skin  upon  dependent  parts  will  be 
discovered  early.  Priapism  or  a  semiflaccid  turgescence  of  the 
penis  occurs.     This  is  not  a  true  "erection"  of  the  organ. 


Fig.  78. — Anterior  view  of  the  areas  of  distribution  of  the  sensory  nerves  of  the  skin  (shown  on 
the  left  side  of  the  body),  and  distribution  of  sensation  according  to  segments  of  the  spinal  cord  (shown 
on  the  right  side  of  the  body),  i,  Ophthalmic  nerve.  2,  Superior  ma.xillary  nerve.  3,  Inferior  max- 
illary nerve.  The  points  of  exit  of  the  supra-orbital,  infra-orbital,  and  mental  nerves  are  shown  by 
the  markings  X.  4,  Points  of  exit  of  the  anterior  intercostal  branches  of  the  intercostal  nerves.  5, 
Points  of  exit  of  the  lateral  branches  of  the  intercostal  nerves.  6,  Intercosto-humeral  nerve.  A.M. 
and  S.C.,  Area  of  distribution  of  the  great  auricular,  superficial  cervical,  and  supraclavicular  branches 
of  the  cervical  plexus.  C,  Circumfiex  nerve.  W,  Nerve  of  Wrisberg.  I.C.,  Internal  cutaneous 
area.  M.S.,  Musculospiral  area.  M.C.,  Musculocutaneous  area.  t/,  Ulnar.  M,  Median.  R, 
Radial.  G.C.,  Genitocrural  area.  The  nerve  is  seen  as  distributing  its  branches  to  the  genital  region 
and  to  the  upper  portion  of  the  thigh.  E.C.,  External  cutaneous  area.  /./.,  Ilio-inguinal  area. 
I.C.U.,  Internal  cutaneous  area  of  the  thigh.  M.C.U.,  Middle  cutaneous  of  thigh.  I.S.,  Internal 
saphenous.  P,  External  popliteal  branches  area.  On  the  right  side  the  division  according  to  seg- 
ments is  seen,  the  letters  C,  D,  L,  and  5  standing  respectively  for  cervical,  dorsal,  lumbar,  and  sacral 
.segments  of  the  cord.  On  the  right  side,  from  the  fourth  dorsal  to  the  twelfth  dorsal  (inclusive),  the 
maximum  points,  according  to  Head,  of  the  abdominal  viscera  are  shown  in  relation  to  the  spinal 
segments  (EiscndrathJ. 

95 


FRACTURES  OF  THE  VERTEBR.E 


Fig.  79. — Cutaneous  nerve  supply  to  the  anterior  surface  of  the  body  (after  Seifier). 


SYMPTOMS 


97 


Fig.  80.— Cutaneous  nerve  supply  to  the  posterior  surface  of  the  body  (after  Seiffer). 


98  FRACTURES  OF  THE  VERTEBR^ 

Symptoms  of  Fracture  of  the  Different  Regions  of  the 
Spine,  the  Cord  Being  Involved. — Injuries  to  the  Last  Dorsal 
and  Lumbar  Vertebra  (see  Figs.  8i,  82,  83). — The  spinal  cord  ends 
opposite  the  lower  border  of  the  first  lumbar  vertebra.  Any 
pressure  at  this  point  or  below  will  involve  the  cauda  equina  in 
whole  or  in  part  (see  Figs.  84,  85).     Local  evidences  of  the  bony 


Fig.  81.— Fracture  of  the  twelfth  dorsal  vertebra.    Anesthesia  to  the  height  of  the  anterior 
superior  spinous  processes  in  front.     Second  lumbar  nerve  involved. 


lesions  may  be  present.  The  paralysis  of  the  legs  may  be  partial 
or  complete.  The  anesthesia  of  the  lower  limbs  is  partial  rather 
than  complete  and  up  to  the  level  of  the  bony  lesion.  Retention 
or  incontinence  of  urine  and  feces  exists.  The  paralyzed  muscles 
rapidly  become  wasted.  Constant  pain  and  hyperesthesia  may 
be  present  both  above  and  below  the  lesion.  The  patellar  and 
plantar  reflexes  are  usually  lost. 

The  prognosis  is  not  altogether  unfavorable  to  recovery.  Par- 
tial recovery  is  possible.  Later,  muscular  contractures  will  exist 
in  the  lower  limbs,  which  impede  walking.  If  at  the  end  of  six 
weeks  evidences  of  beginning  recovery  do  not  appear,  or  if  recovery 
once  begun  has  ceased,  it  will  be  wise  to  operate  upon  injuries  to 
the  Cauda  equina. 


SYMPTOMS 


99 


X 


Fig.  82.  Fig.  83. 

Figs.  82,  83. — Fracture  of  the  twelfth  dorsal  vertebra  without  involvement  of  the  first  lumbar  nerve- 
roots,  the  ilio-inguinal,  iliohypogastric,  and  external  cutaneous  nerves  not  being  involved. 


^ 


I 


Fig.  84.  Fig.  85. 

Figs.  84,  85. — Injury  to  the  caurla  equina,  which  has  involved  llic  third  sacral  nerves.     Fracture  of 

the  first  lumbar  vertebra  or  the  second  lumbar  vertebra. 


lOO 


FRACTURES  OF  THE  VERTEBRA 


Injuries  to    the  Dorsal  Vertehrce — second  to  the  eleventh    (see 
Fig.   86). — The  simple  distribution  of    the  spinal  dorsal  nerves 


?l 


Fig.  86. 


-Si.xth  dorsal  vertebra  fractured.    Anesthesia  at  the  level  of  two  inches  above  the  umbilicus. 
The  eighth  or  ninth  dorsal  nerve  involved. 


Fig.  87. — Lesion  of  spine  between  fifth 
and  sixth  cervical  vertebrae.  Note  position 
of  arms,  due  to  paralysis  of  subscapularis. 
Biceps  brachialis  anticus,  supinator  longus 
and  deltoid  muscles  intact.  Elbow  flexed, 
shoulders  abducted  and  rotated  outward 
(after  Thorburn). 


Fig.  88. — Luxation  of  sixth  and  seventh 
cervical  vertebras ;  typical  attitude ;  center 
for  subscapularis  not  involved.  Contrast 
figures  87  and  88  (after  Kocher). 


below  the  first  makes  the  interpretation  of  injuries  to  this  region 
much  easier  than  similar  injuries  to  the  cervical  or  lumbar  regions. 
The  arms  escape  paralysis.  The  motor  and  sensory  paralysis 
extends  ordinarily  to  the  height  of  the  bony  lesion.  In  a  few  cases 
in  which  the  ner\^e-trunks  within  the  canal  are  not  implicated  the 


SYMPTOMS  lOI 

level  of  the  paralysis  will  be  lower  than  the  lesion.  The  patellar 
reflexes  are  at  first  generally  lost  in  the  severer  types  of  fracture. 
If  the  patient  recovers,  there  will  be  spastic  paralysis  if  the  injury 
is  above  the  lumbar  enlargement.  If  the  lumbar  enlargement  is 
involved,  there  may  be  great  pain  in  the  legs. 

Injuries  to  the  Cervicodorsal  Region,  Opposite  the  Cervical  En- 
largement of  the  Spinal  Cord. — The  arms  escape  paralysis,  per- 
haps, at  first,  but  become  involved  after  several  days.  The 
paralysis  is  often  partial.  Respiration  is  diaphragmatic  only. 
Pain  in  the  arms  is  quite  constant.  If  the  sixth  vertebra  is 
dislocated  upon  the  seventh,  the  intrinsic  muscles  of  the  hand 


Fig.  89. — Lesion  of  spine  between  sixth 
and  seventh  cervical  vertebrae.  Position  in 
case  of  complete  transverse  destruction  of 
the  cord  just  below  nuclei  for  subscapula- 
ris  ;  areas  of  anesthesia  shown  (after  Thor- 
burn). 


Fig.  eo.^Atlas.axis,  and  third  cervical 
vertebra  from  the  front.  Case:  man,  thirty- 
eight  years  of  age  ;  fell  from  a  cart.  Frac- 
ture of  odontoid  process.  Slight  hemor- 
rhage into  the  medulla.  Death  after  forty- 
eight  hours  (Cabot). 


will  be  paralyzed.  If  the  fifth  vertebra  is  dislocated  upon  the 
sixth,  there  will  appear  a  characteristic  position  of  the  upper 
extremities  (see  Fig.  87) :  abduction  of  the  arms,  flexion  of  the 
forearms,  with  rotation  outward  of  the  whole  extremity.  If 
the  injury  is  above  the  sixth  cervical  vertebra,  there  will  be 
anesthesia  of  the  entire  limb  excepting  the  shoulder.  The 
attitude  after  lesions  between  the  sixth  and  seventh  cervical 
vertebrae  is  shown  in  figure  88.  The  characteristic  attitude 
in  lesions  between  the  sixth  and  seventh  cervical  vertebrae  is 
also  shown  in  figure  88. 

Injuries  to  the  Midcervical  Region. — A  lesion  of  the  third  cer- 


I02 


FRACTURES  OF  THE  VERTEBRA 


vical  vertebra  will  involve  the  phrenic  nerve.     The  diaphragm 
will  be  paralyzed.     Death  will  occur  within  a  few  hours. 

In  the  cervical  and  lower  thoracic  regions  self-reducing  disloca- 
tion without  fracture  frequently  occurs.  Clinically,  we  find  an 
injured  man  showing  no  sign  of  fracture  of  the  spine.  There  is 
a  partial  or  complete  paralysis  present.  At  autopsy  no  lesion 
of  bone  is  found,  but  the  spinal  cord  shows  evidences  of  compres- 
sion opposite  an  intervertebral  disk  in  the  cervical  region.  The 
cord  may  appear  crushed  through.  There  must  have  been  a 
dislocation  of  one  body  upon  another  and  an  immediate  reduction 
of  the  dislocation. 


^^ 


Fig.  91. — Fracture  of  the  atlas  and  axis.  Man,  seventy-four  years  of  age;  fall;  immediately  left 
arm  paralyzed.  No  loss  of  consciousness,  speech  thick.  Neck  movements  normal.  Twenty-four 
hours  after  the  accident,  suddenly  difficult  breathing  appeared  and  death  followed  (Brooks). 

Injuries  to  the  First  Two  Cervical  Vertebrae  (see  Figs.  90, 
91). — If  the  displacement  is  slight,  life  may  be  spared  until  sud- 
den displacement  occurs  or  a  secondary  myelitis  causes  death. 
Cases  of  recovery  are  recorded.  Death  usually  occurs  instantly. 
Perhaps  one  person  in  fifty  thus  injured  recovers  (Gowers).  For 
Dislocation  of  the  Cervical  Vertebra  see  Chapter  XXIII. 

Mixter  and  Osgood  give  a  good  review  of  the  literature  of  in- 
juries to  the  atlas  and  axis. 

Violence  is  the  common  cause  of  injury  to  the  first  two  cervical 
vertebrae.  This  violence  may  be  apparently  very  slight,  from 
muscular  action  only.  The  most  frequent  lesion  is  a  unilateral 
subluxation  or  true  dislocation  without  fracture.      (vSee  Disloca- 


DIAGNOSIS 


103 


tion  of  Cervical  Vertebra,  Chap.  XXIII.)    Fracture  of  the  odontoid 
together  with  rotary  dislocation  is  the  next  most  common  lesion. 

The  arches  or  lateral  masses  of  the  altas  or  axis  are  fractured  with 
or  without  accompanying  dislocations  and  fractures  of  the  odontoid. 

Early  Symptoms. — These  may  vary,  from  instant  death  to  a 
simple  stiffness  of  the  neck  and  a  slight  asymmetry  of  the  head 
position.  Severe  occip- 
ital neuralgias  and  much 
rigidity  with  an  increase 
of  the  pain  on  any  at- 
tempted action  or  pas- 
sive movement  of  the 
head  are  nearly  always 
present  and  should  lead 
one  to  suspect  a  bony 
lesion. 

Later  Symptoms. — The 
rigidity  and,  as  a  rule, 
the  occipital  neuralgia 
persist.  Sudden  move- 
ment or  attempts  at  re- 
duction are  often  fol- 
lowed by  immediatelv 
fatal  consequences.  The 
most  serious  changes 
may  occur  in  the  spinal  cord,  a  myelitis,  caused  by  pressure  of 
bone  or  of  callus. 

Diagnosis. — The  X-ray  will  demonstrate  the  lesion  in  a  lateral 
view  or,  taken  anteroposteriorly,  through  the  wide  open  mouth.  By 
this  latter  view  an  odontoid  fracture  may  be  demonstrated  readily. 

If  it  can  be  demonstrated  that  a  simple  unilateral  dislocation 
of  the  atlas  and  axis  has  occurred  manipulation  offers  an  oppor- 
tunity for  cure  (see  p.  650).  Mixter  and  Osgood  have  recorded  an 
operation  for  the  relief  of  displacement  of  the  atlas  and  axis  due  to 
a  fracture  of  the  odontoid  process.  No  union  took  place  in  the  frac- 
tured odontoid.  At  operation  the  arch  of  the  atlas  when  replaced 
by  backward  digital  pressure  through  the  pharynx  was  held  securely 
and  fastened  to  the  spine  of  the  axis  by  silk  passed  about  it.  A 
good  recovery  followed  with  relief  of  the  occipital  neuralgia. 


Fig.  92. — X-ray  lateral  view  of  a  fracture  of  the  odontoid 
process  with  displacement.  The  arrow  points  to  region  con- 
cerned. Compare  with  Fig.  93  of  normal  plate.  Numbering 
same  as  in  Fig.  93-  Note  the  relations  between  atlas  and  axis. 
(Case  of  Mixter  and  Osgood.) 


I04 


FRACTURES  OF  THE  VERTEBRi^ 


Cases  of  fracture  of  the  arches  of  the  first  two  cervical  verte- 
brae are  best  treated  by  permanent  immobiUzation. 

Prognosis. — The  prognosis  depends  upon  the  amount  of 
injury  to  the  spinal  cord.  The  prognosis  is  less  grave  than  it 
was  thought  to  be  a  few  years  ago.  There  is  a  probability  of 
saving  a  certain  proportion  of  cases.     In  general,  the  nearer  the 


Fig.  93. — X-ray  lateral  view  of  a  normal  base  of  skull  and  cervical  spine.  The  arrow  points  to 
region  concerned:  i,  Styloid  process;  2,  inferior  maxilla,  near  its  angle;  3,  cervical  spinous  processes; 
occipital  bone;  5  body  of  vertebra.     (Case  of  Mixter  and  Osgood.) 

fracture  approaches  the  medulla  oblongata  and  the  foramen 
magnum,  the  more  serious  does  the  outlook  become.  Patients 
with  fracture  in  the  dorsal  and  lumbar  regions  die  in  the  course 
of  months  from  cystitis,  pyelitis,  and  exhaustion.  Patients  with 
fractures  in  the  upper  dorsal  and  lower  cervical  regions  die  in  a 
few  days  or  weeks  from  hypostatic  pneumonia.  Patients  with 
fractures  high  up  in  the  cervical  region  die  instantly  or  in  a 
few  hours  from  shock  and  direct  pressure  upon  the  medulla 
oblongata.  After  an  injury  to  the  back  which  prevents  a  man 
from  rising,  he  should  be  placed  on  a  flat  stretcher.  The  position 
assumed  after  the  injury  should  be  maintained,  if  it  does  not  en- 
danger life,  until  the  surgeon  sees  the  case.  After  examining  the 
patient  he  should  be  aseptically  catheterized.  More  accurate 
knowledge  of  the  function  of  the  kidneys  will  then  be  obtained 
during  the  first  twenty-four  hours. 


TREATMENT 


105 


Treatment. — The  object  of  treatment  is  to  relieve  the  cord 
from  pressure  and  to  immobilize  the  fracture.  The  cord  will 
be  uninjured,  slightly  injured,  or  injured  seriously.  If  the 
cord,  judging  by  clinical  signs,  is  uninjured,  the  bony  parts  may 
be  left  untouched  or  they  may  be  replaced  by  manipulation  or 
operation.  If  the  cord  is  injured,  the  prognosis  of  operative  in- 
terference will  depend  upon  whether  the  lesion  of  the  cord  is  trans- 
verse and  complete,  or  whether 
it  is  partial.  It  is  important, 
therefore,  to  distinguish  between 
the  signs  of  a  transverse  lesion 
and  those  of  a  partial  lesion.  In 
a  complete  transverse  lesion  the 
history  of  the  onset  of  the 
symptoms  is  a  sudden  one,  the 
symptoms  appear  immediately 
following  the  fracturing  trauma; 
whereas  if  a  partial  injury  is 
present,  an  interval  will  have 
elapsed  before  the  symptoms 
develop;  the  appearance  of 
symptoms  is  gradual  rather  than 
sudden.  In  a  complete  trans- 
verse lesion  the  motor  paraly- 
sis is  found  to  be  complete, 
and  the  paralyzed  muscles  are 
flaccid;  whereas  if  the  lesion 
is  a  partial  one,  the  motor  par- 
alysis is  limited,  some  muscles 
of  the  limbs  are  paralyzed, 
others  are  not,  and  there  is  often 
noticed  muscular  spasm  in  the 
affected  limbs.  In  a  complete 
transverse  lesion  sensation  is 
entirely  gone;  whereas  in  a  partial  lesion  some  seilsation  is 
present.  The  knee-jerks  are  variable;  in  the  complete  trans- 
verse lesion  they  are  absent.  In  the  partial  lesion  the  knee-jerks 
are  apt  to  be  absent  at  first,  and  they  may  return  later.  In 
the  transverse  lesion  the  paralysis  of  the  bladder  and  rectum  is 


Fig.  94. — Fracture  of  tlie  cervical  spine; 
cord  compressed  by  bone,  torn  and  displaced 
intervertebral  disc,  and  blood.  Hemorrhage 
into  the  cord  at  the  seat  of  the  lesion  and  below 
the  lesion  (Warren  Museum).  (Drawn  by 
Byrnes.) 


io6 


FRACTURES  OF  THE  VERTEBRA 


Fig.  95- — Spine  sawed  in  sagittal  sec- 
tion, showing  fracture  through  the  inter- 
vertebral disc  between  the  sixth  and 
seventh  cervical  vertebrae,  with  disloca- 
tion forward  of  the  upper  fragment.  Par- 
tial crush  of  the  cord  (Thomas). 


Fig.  96. — Spine  sawed  as  before.  Fracture 
of  the  spinous  processes  of  the  seventh  cervi- 
cal and  first  and  second  dorsal  vertebrae. 
Fracture  of  the  bodies  of  the  fifth,  sixth,  and 
seventh  cervical  vertebras  with  displacement 
backward  of  the  upper  fragment.  Total  crush 
of  the  cord.  The  section  passes  a  little  to  one 
side  of  the  cord,  which  is  seen  in  place,  and 
the  staining  of  the  cord  by  hemorrhage  into  its 
substance  shows  plainly  through  the  mem- 
branes even  in  the  photograph.  The  spinous 
processes  of  the  second  and  third  dorsal  verte- 
brae were  found  fractured  at  the  operation,  and 
were  removed  (Thomas). 


Fig.  P7.  Fig.  98. 

Figs.  97  and  08. — Spine  sawed  as  before.  Fracture  of  spines  of  fifth  cervical  and  fourth, 
fifth,  and  sixth  dorsal  vertebree.  Fracture  of  body  of  sixth  dorsal  vertebra.  Displacement 
forward  of  upper  fraj^ment.  Total  crush  of  the  cord,  the  softened  substance  of  which  has 
been  removed  by  the  saw,  leaving  only  the  empty  and  blood-stained  meninges  at  this  point. 
Figure  97  shows  the  spine  as  sawed;  figure  98,  the  same  hyperextended,  showing  the  oblitera- 
tion of  the  narrowing  of  the  spinal  canal  (Thomas). 

107 


io8 


FRACTURES  OF  THE  VERTEBRA 


complete ;  whereas  in  the  partial  lesion  paralysis  of  these  organs  is 
not  always  present.  Priapism,  sweating,  and  involuntary  muscular 
twitchings  are  seen  more  commonly  in  case  of  injury  to  the  spine 
associated  with  complete  lesions  of  the  cord  than  in  cases  with 


Fig.  99.  Fig.  100. 

Figs.  99  and  100.-  The  two  halves  of  the  spine  sawed  in  sagittal  section.  Fracture  of  the 
seventh  cervical  vertebra,  with  dislocation  forward  of  the  upper  fragment.  Fracture  of  the 
arch  of  the  sixth  and  of  the  spine  of  the  seventh  vertebrae.  Total  crush  of  the  cord.  The 
discoloration  of  the  cord  from  blood  shows  plainly  in  the  plate  (Thomas). 


partial  lesions  of  the  cord.  In  partial  lesions  variations  from  the 
definite  types  of  symptoms  are  seen.  The  symptoms  are  more  or 
less  irregular.  In  total  lesions  of  the  cord  operation  may  do  good. 
The  cases  of  pressure  from  fragments  of  bone — that  is,  those  oc- 
curring for  the  most  part  in  the  cervical  region,  in  which  the 


TREATMENT 


109 


laminae  of  the  vertebrae  are  fractured — demand  operation.  All 
other  cases  of  bony  pressure  are  those  due  to  dislocation  of  verte- 
brae which  are  remediable  either  by  operation  or  manipulation. 
In  these  cases  the  prognosis  depends  upon  the  damage  done 
the  cord. 

It  is  the  result  of  experience  that  in  cases  of  injury  to  the 
Spine  severe  enough  to  do  damage  to  the  cord  probably  irrepar- 
able injury  has  been  done  by  either  a  distinct  crush  of  the  cord  or 
hemorrhage  into  the  cord  occurring  at  the  time  of  the  primary 
trauma.     Hemorrhage  into  the  cord  takes  place  often  extensively 


Fig.  loi. — Case:   Man,  fracture  of  spine;   transverse  section  of  spinal  cord  above  the  lesion.     Hem- 
orrhage into  posterior  horn  (Taylor).     (Drawn  by  Byrnes.) 


and  some  distance  from  the  seat  of  the  chief  lesion,  so  that  even 
if  the  seat  of  the  crush  of  the  cord  were  reached  by  operation, 
damaging  lesions  would  still  remain  unrelieved. 

It  is  also  a  result  of  experience  that  removal  by  operation  of 
the  laminae  and  spines  of  the  vertebrae  in  the  suspected  region 
of  fracture  very  rarely^almost  never — reveals  any  remediable 
condition  or  affords  any  evidence  of  the  exact  seat  of  the  lesions 
or  their  extent.  The  reason  for  these  facts  is  that  the  dura  at 
the  seat  of  a  crush  of  the  cord,  whether  partial  or  complete,  re- 
mains intact  and  untorn,  and  that  extradural  hemorrhage  is 
unusual.     The  surgeon,  therefore,  after  removal  of  the  laminae, 


no 


FRACTURES  OF  THE  VERTEBRA 


is  as  much  in  doubt  as  he  was  before,  excepting  that  he  knows 
that  he  has  removed  pressure  from  the  cord  and  has  diminished  the 
hkehhood  of  subsequent  pressure.  Operation  in  complete  lesions 
holds  out  but  little  hope  of  benefit.  It  is  said  that  the  chances 
of  the  symptoms  being  due  to  pressure  by  extradural  blood-clot 
or  bone  justify  operative  interference  in  these  apparently  hope- 
less cases.  This  is  true  in  those  cases  in  which  the  lesion  of  the 
cord  is  partial.  When  the  lesion  is  completely  transverse  opera- 
tion may  relieve. 

Operative  interference,  then,  may  he  summarized  somewhat 
as  follows: 

In  partial  lesions  operation  may  be  demanded;  in  fracture 
of  the  laminae  and  spines  operation  is  demanded;  in  all  lesions 


Fig.  102 


-Case:  Man,  fracture  of  spine;  transverse  section  of  spinal  cord  above  the  lesion.     Hem- 
orrhage into  posterior  horn  (Taylor).     (Drawn  by  BjTnes.) 


of  the  Cauda  equina  operation  is  demanded;  in  almost  all  sup- 
posedly complete  lesions  operation  may  be  done  with  the  hope 
of  doing  some  little  good. 

The  following  position  seems  the  wise  one  for  the  surgeon  to 
take  in  cases  of  fracture  of  the  vertebrae,  particularly  since  a  few 
cases  have  been  recently  recorded  (notably  Mixter's,  reported  by 
Chase)  in  which  life  was  prolonged  in  comfort  following  operation 
in  what  appeared  clinically  to  be  a  complete  transverse  lesion  of 


TREATMENT 


III 


the  cord.     This  position  here  stated  is  that  of  Walton,  and  the 
evidence  existing  supports  the  wisdom  of  the  position. 

There    are    no    symptoms    which    estabhsh     (otherwise    than 
through  their  persistence)  irremediable  crush  of  the  cord. 


p;g_  J03 — Fracture  of  the  spine  with  crush  of  the  cord.  Hematomyeha  some  distance  from  the  seat 
of  injury.  Dura  intact.  The  third  of  the  cross-sections  shows  the  condition  of  the  cord  at  the  level 
of  the  crush.     The  paralysis  was  complete,  yet  at  operation  dura  was  intact  (Walton). 

While  total  relaxed  paralysis,  anesthesia  of  abrupt  demarka- 
tion,  total  loss  of  reflexes,  retention,  priapism,  and  tympanites, 
if  persistent,  point  to  complete  and  incurable  transverse  lesion. 


112  FRACTURES  OF  THE  VERTEBRA 

the  onset  of  such  symptoms  does  not  preclude  a  certain  degree 
at  least  of  restoration  of  function. 

The  prognosis  without  operation  is  grave. 

While  the  results  of  operation  are  not  brilliant,  they  are  suf- 
ficiently encouraging  to  warrant  us  in  making  the  practice  more 
general. 

In  most  cases  it  will  be  wise  to  operate  within  a  few  days  of 
the  injury,  but  a  delay  of  some  hours  is  advisable,  partly  on  ac- 
count of  shock  and  partly  to  eliminate  the  diagnosis  of  simple 
distortion. 

We  have  no  infallible  guide  to  the  extent  of  the  lesion.  The 
operation  at  the  worst  does  not  materially  endanger  life  nor  affect 
unfavorably  the  course  of  the  case,  and  may  at  least  reveal  the 
lesion  and  lessen  the  pain;  it  may  sometimes  save  a  patient  from 
death  or  from  helpless  invalidism  of  most  distressing  character. 
Instead  of  selecting  the  occasional  case  for  operation,  we  should 
rather  select  the  occasional  case  in  which  it  is  contraindicated 
(the  patient  with  great  displacement  of  vertebrse,  the  patient 
with  high  and  rising  temperature,  the  patient  plainly  moribund, 
the  patient  still  under  profound  shock). 

The  dura  should  be  opened  freely;  it  need  not  be  sutured; 
drainage  is  not  necessary. 

The  fact  that  edema,  congestion,  inflammation  of  the  spinal 
cord,  or  shock  and  infection  (Spiller)  may  result  from  operation 
should  not  cause  one  to  hesitate  to  operate  in  fracture  of  the 
spine. 

It  is  an  interesting  fact  clinically  and  pathologically  that  in 
cords  compressed  at  a  definite  level  with  destruction  of  the 
cord,  at  the  seat  of  compression  there  is  often  found  a  hemato- 
myelia  (hemorrhage  into  the  substance  of  the  cord)  several  ver- 
tebrae above  and  below  the  fracture,  thus  showing  how  extensive 
is  the  acting  force. 

A  study  of  the  drawings  made  from  actual  sections  of  the 
spinal  cords  of  cases  of  fracture  of  the  spine  will  indicate  the 
different  lesions  already  mentioned. 

Figure  94  is  from  a  fracture  of  the  cervical  vertebrae,  showing 
destruction  of  the  cord  at  the  seat  of  the  lesion,  with  localized 
pressure  from  bone  and  blood.     Ivow  down  is  seen  an  extensive 


TREATMENT 


113 


extradural  hemorrhage  and  a  hematomyelia  some  distance  from 
the  original  trauma.    _ 


Fig.  104. — Case  :  Man,  fracture  of  spine  ;  transverse  section  of  spinal  cord  at  the  seat  of 
lesion  (Taylor).     (Drawn  by  Byrnes.) 


Fig.  105. — Case:   Fracture  of  the  spine;  transverse  section  of  spinal  cord  several  segments  from  the 
lesion;   hemorrhage  into  the  white  matter  (Taylor).     (Drawn  by  Byrnes.) 

Figure  loi  is  from  a  dislocation  and  fracture  of  the  fifth  upon 
the    sixth    cervical    vertebra.     There     was    complete    paralysis 
below    the    lesion.     Trephining    was    done.     The    patient    lived 
8 


114  FRACTURES  OF  THE  VERTEBRA 

without  improvement  seventeen  days.  This  section  of  the  cord 
is  taken  a  Httle  above  the  lesion  and  shows  clearly  a  hemato- 
myelia  of  the  right  posterior  cornu. 

Figure  102  is  taken  from  a  section  of  the  cord  of  the  preceding 


Fig.  106. — Partial  fracture  of  twelfth  dorsal  and  fracture  of  first  lumbar  vertebrae.  Fall  of 
twenty  feet  on  nares.  Paraplegia  and  sphincter  paralysis.  Death  nine  months  after  acci- 
dent.   Died  of  phthisis.    Type  of  compression  fracture  (Warren  Museum,  specimen  941). 

case  a  little  below  the  lesion,  showing  complete  destruction 
of  the  gray  matter  of  the  cord;  the  dura  remained  intact. 

Figure  104  is  also  taken  from  a  section  of  the  cord  of  the  pre- 
ceding case,  but  at  the  seat  of  the  lesion,  showing  a  destruc- 
tion of  the  gray  and  white  matter  of  the  cord  anteriorly  next 
to  the  bodies  of  the  vertebrae.  The  dura  remained  intact,  there 
being  to  the  operating  surgeon  no  evidence  posteriorly  of  any 
disturbance  having  occurred  anteriorly. 

Figure  105  is  a  section  of  the  spinal  cord  of  a  woman  who 
fell  from  a  trapeze  to  the  net,  and  fractured  and  dislocated  the 
sixth  cervical  vertebra.      Operation  was  done.      She  Uved  three 


TREATMENT 


115 


days.     A  little  distance    (two   segments)   from  the  seat  of  the 
lesion,  where  the  cord  was  crushed  anteriorly,  was  found  a  hemato- 
myelia  of  the  white  matter  posteriorly.     The  dura  was  intact. 
These  specimens,  which  illustrate  the  common  lesions  of  the 


Fig.  107. — Old  fracture  of  twelfth  dorsal  vertebra,  from  fall  of  thirteen  feet ;  canal  nar- 
rowed. Total  paralysis  of  motion  and  sensation  below  injury.  Died  two  years  after  accident 
(Warren  Museum,  specimen  4629J. 

spinal  cord  following  fractures  and  dislocations  of  the  vertebrae, 
demonstrate  the  utter  futihty  of  operative  interference  in  certain 
cases  of  crush  of  the  cord  with  signs  of  a  complete  transverse 
lesion. 

The  Immediate  Rectification  of  the  Deformity  and  Immobilization 
by  the  Plaster-of -Paris  Jacket. — With  our  present  knowledge  of  the 
pathology  of  these  fractures,  and  excepting  cases  of  fracture  of  the 
vertebral  arch  alone  and  pressure  upon  the  cauda  equina  and  partial 
lesions  of  the  cord,  there  can  be  no  doubt  that  the  most  commonly 
applicable  treatment  for  fracture  ofthe  vertebrae  is  by  means  of 
expectant  methods.      The  methods  are  as  follows:   Immobiliza- 


Il6  IfRACTURES  OF  THE)  VERTEBRA 

tion  of  the  part  by  a  plaster-of- Paris  jacket  applied  to  the  trunk, 
if  there  is  no  deformity.  If  there  is  deformity,  correction  of 
it  and  immobihzation  of  the  spine  in  the  corrected  position. 
The  correction  of  the  deformity  must  be  immediate  to  avoid 
irremediable  softening  of  the  cord  from  pressure;  and  this  may 
occur  even  within  forty-eight  hours. 

Method  of  Applying  the  Plaster-of-Paris  Jacket. — This  differs 


Fig.  io8. — Fracture  of  the  dorsal  vertebrae  with  great  displacement  of  bodies.    The  patient 
lived  two  months  (Warren  Museum,  specimen  No.  6229). 


in  no  respect  from  the  usual  methods  of  application,  with  the 
exception  that  the  patient  should  be  protected  from  any  unusual 
or  sudden  jar  or  movement.  The  trunk  having  been  properly 
protected  by  a  tightly  fitting  shirt,  the  patient  is  carefully  placed 
prone  in  the  hammock.  If  the  hammock  suspension  is  not  avail- 
able, then  the  patient  may  be  placed  prone  upon  two  kitchen 
tables,  which  are  gradually  pulled  apart,  allowing  the  trunk 
to  be  unsupported  between  the  tables  until  the  desired  exten- 
sion is  obtained.  If  the  tables  are  used,  great  care  must  be 
exercised  that  proper  assistants  secure  the  shoulders  and  hips 
of  the  patient  during  the  procedure.  Gentle,  firm  pressure 
is   made  upon  the   projecting  vertebral   spines   until   reduction 


TREATMENT 


117 


is  complete.  The  jacket,  reinforced  posteriorly  by  extra  layers 
of  bandage,  is  then  applied.  Death  may  occur  instantly  during 
this  procedure,  but  if  gentle  measures  are  used,  the  likelihood 
of  such  a  catastrophe  will  be  modified.  An  anesthetic  given 
to  primary  anesthesia  is  often  of  service.  A  sufficient  number 
of  assistants  should  be  on  hand — there  should  be  at  least  four. 
It  is,  of  course,  impossible  to  say  what  cases  will  be  saved  by 


Fig.  109. — Combination  of  compression  and  diagonal  fracture  of  the  fourth  dorsal  vertebra  (Keen's 

Surgery,  after  Kocher). 

this  means,  but  it  has  been  proved  to  be  a  life-saving  measure 
in  a  few  cases.  The  patient  will  be  more  comfortable  and  more 
easily  managed  after  such  a  procedure.  The  hopelessness  of  the 
results  of  fractured  spine  justifies  the  surgeon  in  undertaking 
almost  any  risk. 

Cystitis. — I^ife  may  be  prolonged,  if  not  saved,  by  the  proper 
treatment  of  this  distressing  affection,  which  is  always  associated 
with  fracture  of  the  spine.     In  a  number  of  these  cases  death  is 


Fig.  no. — Fracture  of  the  fourth  and  fifth  lumbar  vertebrae.     Compression  of  the  spinal  cord  (Keen's 
Surgery,  after  Wagner  and  Stolper). 


Fig.  III.     Fracture  and  subluxation;  cervical  vertebrse  united  (J.  Mason  Warren  collec- 
tion, Warren  Museum)  (Walton). 

Ii8 


GUNSHOT  FRACTURES  OF  THE  VERTEBRA 


119 


due  to  a  pyelitis  and  nephritis  following  a  cystitis.  These  com- 
plications may  be  avoided  for  a  definite  time  if  the  bladder  is 
thoroughly  drained  by  urethral  catheter  or  by  perineal  drainage. 
The  bladder  may  be  kept  aseptic  by  douching  regularly  with 
a  solution  of  boric  acid  or  permanganate  of  potash  and  by  the 
internal  use  of  urotropin.  Great  care  should  be  exercised  in  the 
avoidance  of  bed-sores ;  it  is  easier  to  prevent  than  to  cure  them. 
Summary  of  Treatment. — Fracture  of  the  arches  of  the  vertebrae, 
whether  open  or  closed,  should  be  subjected  to  operation.  Frac- 
ture and  compression  of  the  cauda  equina  after  six  weeks  of 
waiting  for  spontaneous  recovery  should  be  treated  by  opera- 
tions In  partial  lesions  of  the  cord  operation  may  be  demanded. 
All  fractures  showing  apparently  complete  transverse  lesion  of 
the  cord  should  be  treated  by  immediate  operation.  Only  pro- 
found shock  requires  reasonable  delay.  The  immediate  fixation 
of  the  spine  by  a  plaster-of-Paris  splint  is  indicated  in  those 
fractures  unoperated  upon.  It  is  also  wise  to  fix  the  spine  by 
the  plaster-of-Paris  splint  after  operation  in  many  cases. 

GUNSHOT  FRACTURES  OF  THE  VERTEBRAE 

These  open  fractures  arrange  themselves  into  three  groups 
for  practical  purposes. 

First  group.  Those  cases  in  which  the  viscera  of  the  thorax 
or  abdomen  are  simultaneously  injured. 

Second  group.  Those  cases  in  which  the  bullet  has  entered 
the  spinal  canal  and  has  injured  the  spinal  cord. 

Third  group.  Those  cases  in  which  the  spines  and  laminae 
or  the  arches  of  the  vertebrae  are  injured. 

Treatment. — In  all  cases  the  external  wound  should  be  care- 
fully cleansed  and  protected  by  an  antiseptic  dressing. 

The  degree  of  shock  should  be  observed.  Any  signs  of  a 
lesion  of  the  cord  should  be  recorded.  Evidence  of  damage 
to  the  viscera  within  the  chest  or  abdomen  should  be  sought 
for. 

In  the  absence  of  great  shock  it  is  wise  for  the  surgeon,  under 
antiseptic  and  aseptic  conditions,  to  lay  open  the  wound,  to 
thoroughly  disinfect  it  and  to  attempt  to  ascertain  the  condi- 
tion  of   the   cord   and   vertebrae.     If   the   symptoms   point   im- 


I20  FRACTURES  OF  THE  VERTEBRAS) 

mediately  to  a  transverse  lesion  of  the  cord  extensive  operation 
is  contraindicated. 

The  character  of  the  damage  done  by  the  bullet  to  the  verte 
brge  and  spinal  cord  can  not  be  wholly  determined  except  by 
operation.  In  operating  there  is  always  the  possibility  of  dimin- 
ishing the  chances  of  infection  through  the  bullet  wound  and 
of  relieving  pressure  upon  the  spinal  cord  from  blood  clot  and 
fragments  of  bone. 

A  crushed  cord  is  not  incompatible  with  life.  Such  a  patient 
may  live  for  several  months  or  even  for  several  years.  Opera- 
tion may  prevent  death  from  sepsis,  even  if  a  crush  of  the  cord 
exists. 


CHAPTER  IV 
FRACTURES  OF  THE  RIBS 

Anatomy. — Palpation  of  most  of  the  ribs  is  comparatively 
easy.  The  upper  seven  ribs  on  each  side  articulate  with  the 
sternum.  The  eighth,  ninth,  and  tenth  ribs  are  connected  by 
the  costal  cartilages  anteriorly,  but  the  eleventh  and  twelfth 
ribs  have  no  anterior  attachment.  These  lowest  ribs  are,  there- 
fore, less  liable  to  fracture.  The  first  two  ribs  are  somewhat 
protected  by  the  clavicle  from  direct  violence,  although  great 
depression  of  the  shoulder  may  bring  the  clavicle  to  bear  directly 
upon  the  first  ribs,  and  this  may  be  a  cause  of  fracture.  The 
ribs  are  so  elastic  in  childhood  that  fracture  then  is  extremely 
rare.     Direct  violence  is  the  common  cause  of  fracture. 

Symptoms. — In  partial  fractures  there  may  be  no  symp- 
toms. Upon  forcible  expiration  (as  in  sneezing,  coughing, 
laughing,  crying,  or  in  breathing  hard)  pain  may  be  felt  at  the 
seat  of  fracture.  So  definite  is  the  pain  that  the  patient  may 
be  able  to  place  his  finger  accurately  upon  the  seat  of  fracture. 

Crepitus  is  often  felt  by  the  patient  when  moving  or  mak- 
ing an  expulsive  effort.  Crepitus  is  elicited  for  the  examiner 
by  firmly  placing  the  palm  of  the  hand  flat  upon  the  chest  at 
the  supposed  seat  of  fracture  when  the  patient  coughs.  If 
crepitus  is  present  at  the  time  of  coughing,  a  slight  crunch  or 
click  will  be  felt  and  sometimes  heard.  The  stethoscope  placed 
near  the  supposed  fracture  will  often  assist  in  detecting  the 
crepitus.  The  ribs  should  be  palpated  systematically,  and  the 
chest  slightly  compressed  between  the  two  open  hands  antero- 
posteriorly  and  laterally  to  detect  crepitus.  The  natural  in- 
clination of  the  ribs  should  be  borne  in  mind  during  palpation. 
Respiration  will  be  short  and  catchy,  and  accompanied  by  a 
characteristic  grunt. 

The  attitude  and  movements  of  the  patient  are  very  deliberate, 


122  FRACTURES    OF   THE    RIBS 

guarded,  stiff,  and  in  severe  cases  suggest  the  movements  of  a 
child  with  acute  caries  of  the  dorsal  spine.  There  may  be  a 
slight  cough. 

Complications  of  Fracture  of  a  Rib. — Injury  to  the  pleura 
and  lung  not  uncommonly  occurs.  Its  existence  is  manifested 
by  cough,  bloody  expectoration,  and  emphysema.  Emphysema 
may  extend  over  the  whole  chest  and  up  over  the  neck  and 
face  (see  Fig,  112),  and  even  over  most  of  the  body.  Emphy- 
sema unassociated  with  a  wound  of  the  superficial  soft  parts 
is  of  little  importance.     Pneumothorax  may  be  present.     If  the 


Fig.ii2— Case  :  Emphysema  following  fracture  of  the  ribs  on  the  right  side.     Note  the  puflS- 
ness  of  the  face — the  eyes  almost  closed  (Warren). 


physical  signs  of  pneumothorax  are  associated  with  only  mod- 
erate dyspnoea,  very  careful  immobihzation  of  the  fracture  should 
be  attempted  and  morphine  administered.  If  the  dyspnoea 
becomes  alarming  aspiration  of  the  chest  to  remove  the  air  from 
the  pneumothorax  should  be  practised.  Injury  to  the  heart  and 
pericardium  and  hemorrhage  from  an  intercostal  artery  are 
unusual.  A  dry  pleurisy,  disappearing  rapidly,  localized  at  the 
seat  of  fracture,  is  quite  commonly  detected  by  the  stethoscope. 
The  relations  of  a  rib  to  the  pleura  and  intercostal  vessels  are 
important   in   this   connection    (see   Fig.    115). 


TREATMENT 


123 


Fig.  113.— Fracture  of  ribs.      Emphysema   general.     Adhesive-plaster  swathe  about   chest.      Note 
closure  of  right  eye  and  puffiness  of  face  and  hands  (Monks). 


Fig.  114. — Same  case  as 


gure  113.      Emphysema  entirely  disappeared.     Contrast  the  two  appear- 
ances (Monks). 


Treatment. — The  complications  must  be  attended  to  accord- 
ing to  medical  principles.  A  cough  mixture,  if  necessary,  con- 
taining morphin  is  a  great  help  during  thefirst  week.  It  is  often 
difficult  to  reduce  a  fracture  of   a  rib  and  to  hold  it  reduced. 


124 


FRACTURES    OF    THE    RIBS 


The  deformity  and  loss  of  function  consequent  upon  the  union 
of  a  fractured  rib  in  malposition  are  fortunately  not  very  great. 
However,  the  relief  of  the  patient  upon  the  partial  immobili- 
zation of  the  fracture  is  great.-  By  pressure  of  the  hand  the 
ribs  may  be  steadied  and  the  fragments  brought  into  excellent 
apposition,  and  by  a  pad  held  in  place  by  a  swathe  of  adhesive 
plaster  this  apposition  can  be  maintained.  The  application 
of  an  adhesive-plaster  swathe  is  attended  with  much  comfort, 
and  is  easily  accomplished.  The  swathe  should  be  broad  enough 
to  cover  the  chest  six  inches  on  either  side  of  the  fracture  of  the 
rib,  and  long  enough  to  extend  three-fourths  of  the  way  around 


Supracoslal  branch 


Posterior  branch 
Communicaling  branch 

M.  intercostalis  int. 

Intercostal  vein 
Intercostal  artery 
Intercostal  nerve 


Pleura  (cut  edge) 
Sympathetic  nerve 


Intercostal  vein 
Intercostal  artery 


Azygos  major  vein 


Sympathetic  ganglit 


Great  splanchnic  nen-e 


Fig.  115. — The  right  intercostal  region.  In  the  upper  of  the  three  intercostal  spaces  represented 
the  pleura  in  still  intact  ;  in  the  second  it  has  been  removed  ;  in  the  third,  the  internal  intercostal  mus- 
cle as  well  as  the  pleura  has  been  taken  away.  Fracture  of  a  rib  may  cause  serious  injury  to  pleura, 
vessel,  and  nerve  (Schultze  and  Stewart). 

the  body.  It  is  applied  as  follows :  One  end  is  fixed  to  the  trunk 
of  the  patient  at  the  spine,  the  patient  standing  erect  with  the 
hands  upon  the  top  of  the  head  (see  Fig.  116).  The  surgeon, 
taking  the  loose  end  of  the  swathe  and  holding  it  taut,  walks 
around  the  patient,  applying  the  swathe  to  the  patient's  chest 
while  the  patient  standing  turns  as  if  on  a  pivot  toward  the 
surgeon  if  possible  (see  Fig.  117)-  It  is  important  to  avoid 
covering   the   constantly  moving   abdomen  by  the  swathe.      A 


Fig.  iio. — Fracture  of  the  ribs.  Starting  the  application  of  the  adhesive-plaster  swathe 
to  encircle  the  trunk.  Fixation  of  initial  end  of  the  swathe  at  the  spine.  Notice  that  the 
swathe  is  held  taut  as  it  is  applied. 


Fig.  117. — Fracture  of  the  ribs.     Fiiiishiiif,' the  application  of  the  adhesive-plaster  swathe  to 

the  trunk. 

125 


126  FRACTURES    OF    THE    RIBS 

swathe  made  of  several  long  strips  of  adhesive  plaster,  each  strip 
being  four  inches  wide,  imbricated  in  the  application,  will  often 
prove  more  comfortable  than  a  single  swathe.  The  comfort  attend- 
ing the  wearing  of  such  a  swathe  speaks  much  for  its  efficacy. 

Operative  Treatment. — If  the  fracture  is  comminuted  or  if 
there  is  great  displacement  that  is  irreducible  by  pressure,  an 
incision  and  elevation  of  the  parts  and  immobilization  by  suture 
are  to  be  considered. 

Ajter'treatment. — The  upright  position  will  give  the  most  com- 
fort. The  swathe  should  be  changed  at  least  once  each  week. 
It  will  require  about  three  weeks  for  the  union  to  become  firm. 
A  cotton  swathe  may  be  worn  during  the  third  and  fourth  weeks 
in  place  of  the  adhesive-plaster  swathe.  At  the  end  of  four 
weeks  all  swathes  may  be  removed.  Massage  to  the  seat  of 
fracture  will,  after  the  first  week,  hasten  healing  and  a  restora- 
tion of  the  parts  to  the  normal  position.  If  there  have  been 
any  pleural  or  lung  complications,  great  precaution  should  be 
exercised  in  the  after-care.  The  avoidance  of  exposure  to  cold 
and  of  great  bodily  exertion  for  a  period  of  two  months  or  more 
following  recovery  from  the  complication  is  necessary. 

Other  injuries,  such  as  strains  of  the  shoulder  and  back,  are 
likely  to  appear  some  days  after  the  acute  symptoms  of  a  frac- 
ture of  the  rib  have  subsided.  It  is  well  to  examine  the  patient 
with  a  fractured  rib  for  associated  injuries.  These  associated 
sprains  often  cause  considerable  anxiety  to  the  patient  for  fear 
that  more  serious  trouble  than  a  broken  rib  exists.  In  patients 
over  fifty  years  old  "neuralgic  pain"  at  the  seat  of  fracture 
will  sometimes  persist  for  several  weeks  after  the  fracture  is 
firmly  united.  This  may  be  relieved  by  applications  of  moist 
heat  to  the  affected  part  and  by  counterirritation  of  a  more 
vigorous  kind.  The  use  of  tincture  of  iodin  and  blisters  is  often 
a  great  help.  In  the  aged  the  shock  of  the  injury  is  consider- 
able.    In  feeble  persons  a  pleurisy  or  pneumonia  may  prove  fatal. 

Treatment  directed  to  the  removal  of  the  emphysema  is  or- 
dinarily unnecessary.  The  emphysema  usually  disappears  in  a 
week  or  ten  days.  If  the  distention  of  the  subcutaneous  tissues 
is  extremely  painful  and  increases  very  rapidly  it  may  be  wise 
to  make  several  antiseptic  incisions  over  them,  allowing  the 
air  to  escape,  to  relieve  the  tension  of  the  skin. 


CHAPTER  V 

FRACTURES  OF  THE  STERNUM 

It  is  difficult  to  palpate  the  sternum  accurately.  The  epi- 
stemal  notch  is  felt  between  the  two  inner  ends  of  the  clavicles. 
The  junction  between  the  first  and  second  portions  of  the  sternum 
is  distinctly  felt  opposite  the  second  costal  cartilage  as  a  ridge. 
The  common  site  of  fracture  is  shown  in  figure  1 18.     The  fracture 


Common  situation  of 
fracture. 


Manubrium. 


■  Body. 


Ensiform  process. 
Fig.  ii8. — Sternum  of  an  adult.     Note  separation  at  junction  of  manubrium  and  body. 

that  is  usually  due  to  direct  violence  is  seated  in  the  upper  part 
of  the  second  portion  of  the  sternum,  near  the  junction  of  the 
first  and  second  portions.  The  upper  fragment  is  displaced 
backward  behind  the  upper  end  of  the  lower  fragment.  The 
displacement,  the  abnormal  mobility,  and  possibly  crepitus  after 

each  respiratory  act  or  upon  coughing,  the  locahzcd  area  of  pain, 

127 


128 


FRACTUREIS    OP    THE    STERNUM 


all  increased  by  pressure  and  deep  inspiration  help  to  make  the 
diagnosis  certain.  Percussion  may  discover  dulness  if  there  is 
an  hematoma  of  the  anterior  mediastinum. 

The  patient  stands  in  a  characteristic  fashion  with  body  bent 
forward.  It  is  almost  impossible  to  distinguish  a  dislocation 
at  the  junction  of  the  first  and  second  portions  of  the  sternum 
from  a  fracture  within  the  first  portion  of  the  sternum.  Care- 
ful palpation  alone  and  consideration  for  the  age  of  the  patient 
will  enable  one  to  decide.  The  ossification  of  the  sternum  takes 
place  irregularly.  At  the  twenty-fifth  year  all  parts  are  usually 
ossified.  The  lesions  sometimes  associated  with  fracture  of 
the  sternum — viz.,  fracture  of  the  ribs  and  injury  to  the  lungs 


Fig.  up- — Position  in,  and  method  of  reduction  of,  fracture  of  the  sternum.     Notice  positions 
of  hands  of  sursfeon  and  assistant. 


and  heart — are  usually  so  severe  that  the  patient  does  not  re- 
cover from  them.  If  no  complicating  lesions  are  present,  the 
outlook  for  recovery  is  favorable.  It  is  very  important  to  ex- 
amine the  anterior  thorax  after  falls  upon  the  head  and  shoulders. 
Treatment  of  Fracture  of  the  Sternum. — Spontaneous  re- 
duction has  occurred  in  several  instances  upon  coughing  or 
sneezing.  If  the  patient  is  placed  upon  his  back  with  his  head 
extended  over  the  end  of  the  table  and  the  arms  are  then  raised 
above  the  head  and  rotated  outward  slowly  and  forcibly,  the 
deformity    is    sometimes    reduced.     The    body    of    the    patient. 


TREATMENT    OF    FRACTURE    OF    THE    STERNUM  129 

meanwhile,  is  steadied  by  an  assistant.  Traction  and  counter- 
traction  are  thus  made  upon  the  two  fragments  (see  Fig.  119). 
An  adhesive-plaster  swathe  should  be  placed  about  the  chest 
high  up,  and  held  firmly  in  position  by  straps  across  the  shoulders. 
Union  takes  place  in  from  three  to  four  weeks.  The  fracture 
is  not  solid  for  from  six  to  eight  weeks.  After  resting  on  the 
back  in  bed  for  three  weeks  the  patient  may  be  allowed  to  be 
up  occasionally  with  care  to  avoid  violent  exertion.  For  the 
greatest  precaution  a  Taylor  steel  back-brace,  with  apron  and 
head-support,  should  be  used  for  two  months  after  the  patient 
is  up  and  about.  This  brace  is  similar  to  that  used  in  high  dorsal 
caries  of  the  spine. 

Operative  Treatment. — Incision  and  elevation  of  the  depressed 
fragment  have  been  done  successfully,  and  are  to  be  considered 
in  difficult  cases  after  the  shock  of  the  original  injury  has  passed 
away.  Cyanosis  and  dyspnea  may  be  in  part  dependent  upon 
the  displacement  of  the  sternal  fragments.  Relief  from  these 
symptoms  is  often  immediate  upon  the  correction  of  deformity. 
If  there  are  alarming  symptoms  immediately  following  the  injury 
operative  attempts  at  rehef  of  the  deformity  are  justifiable  and 
wise. 


CHAPTER  VI 

FRACTURES  OF  THE  PELVIS 

The;  pelvic  bones  are  generally  considered  inaccessible  see 
Fig.  120) ;  but  with  a  systematic  anatomical  examination,  espe- 
cially if  assisted  by  digital  examination  by  the  rectum  and 
the  vagina,  practically  all  parts  of  the  pelvic  bones  may  be  pal- 
pated.    Movement  of  the  hip  will  often  determine  the  integrity 


Fig.  120. — Normal  pelvis.    Note  relations  of  pelvic  ring. 

of  the  acetabulum,  which  is,  of  course,  most  difficult  to  palpate 
even  posteriorly  by  the  rectum.  Fractures  of  the  pelvis  are 
occasioned  by  great  violence.  Fracture  occurs  most  often  in 
falls  from  a  height,  and  is  due  to  the  sudden  pressure  upon  the 
pelvis  through  the  thighs  and  hips  or  through  the  spinal  column 

130 


EXAMINATION  FOR  FRACTURES  OF  THE  PELVIS     131 

Upon  the  sacrum  and  sacro-iliac  synchondroses.  Anteroposterior 
pressure  and  lateral  compression,  as  in  the  car-coupling  accident, 
are  common  causes  of  fracture.  From  a  clinical  standpoint  these 
fractures  fall  into  two  groups — fractures  of  the  individual  bones 
without  injury  to  viscera,  and  fractures  at  different  points  in  the 
pelvic  ring  usually  associated  with  visceral  lesions. 

Fractures  of  the   sacrum,   the  coccyx,   the  symphysis  pubis, 
and  the  ischium  are  extremely  rare. 


Fig.  121. — Lateral  view  of  adult  pelvis. 

Examination. — The  examination  should  be  systematically 
made  in  order  to  cover  thoroughly  the  irregular  bones  of  the 
pelvis.  The  ilium  of  each  side  should  be  palpated  to  detect 
a  fracture  of  either  crest.  Then  the  two  ilia  should  be  crowded 
gently  but  firmly  together  in  order  to  determine  crepitus  due  to 
the  presence  of  fracture  elsewhere.  Then  the  pubis  and  ischium 
upon  the  two  sides  are  to  be  palpated  externally  as  far  as  is 
practicable.  Finally  a  careful  rectal  and  vaginal  examination 
should   be   made   of  the   pelvic   bones.     The   patient  should   be 


132  FRACTURES    OF   THE    PELVIS 

catheterized  to  assist  in  determining  the  presence  of  an  injury 
to  the  urinary  tract. 

Fracture  of  the  Ilium  (see  Fig.  122). — This  fracture  is  not 
unusual.  The  crest  of  the  iHum  is  commonly  broken.  Pain, 
swelling,  crepitus,  and  abnormal  mobility  ma}^  be  present.  Local- 
ized tenderness  at  the  seat  of  fracture  may  be  the  only  sign  pres- 
ent. Crepitus,  absent  at  first,  may  be  elicited  several  days 
after  the  injury.  There  is  comparatively  little  displacement. 
Union  occurs  in  from  three  and  a  half  to  four  weeks.  The  pa- 
tient ordinarily  only  requires  restraint  in  bed.  The  outlook 
is  for  a  good  recovery  unless  there  is  a  visceral  lesion.  Slight 
deformity  may  be  noticeable  upon  full  recovery  (see  Fig.  123). 

Fracture  of  the  pubic  portion  of  the  ring  of  the  pelvis  is  the 
commonest  fracture.  It  is  usually  associated  with  other  frac- 
tures or  separations  of  bony  surfaces  of  the  pelvis.  Injury  to 
the  urethra  is  not  uncommon  in  this  fracture  (see  Figs.  124,  125). 

Treatment. — A  snugly  fitting  swathe  encircling  the  pelvis 
should  be  applied  to  assist  in  immobilizing  the  fracture.  If 
the  fracture  is  of  the  ilium  alone,  the  swathe  should  be  applied 
loosely  enough  to  avoid  displacing  the  fragment  of  the  crest 
inward,  thus  causing  permanent  deformity  (see  Fig.  123).  The 
patient  should,  in  all  cases,  except  simple  fractures  of  the  crest 
of  the  ilium,  be  placed  upon  a  properly  fitting  Bradford  frame. 
Upon  this  frame,  and  in  no  other  way,  can  the  patient  be  com- 
fortably nursed.  The  bed-pan  can  be  adjusted  with  ease  and 
without  disturbing  the  fracture.  The  bed  can  be  most  readily 
changed  and  the  patient  kept  clean  and  comfortable.  If  it  is 
probable  that  movements  of  the  hip-joints  cause  motion  at  the 
seat  of  the  fracture,  the  thighs  should  be  fixed  so  as  to  immobilize 
these  joints.  The  long  outside  wooden  splint  extending  from 
the  axilla  to  below  the  heel  and  attached  at  its  foot  end  to  a 
slat  at  right  angles  to  the  long  upright — a  T-splint — is  the  simplest 
means  of  securing  this  immobilization.  If  the  patient  is  on  a 
Bradford  frame,  sufficient  immobilization  is  easily  accomplished 
by  encircling  the  thighs  separately  or  together  and  the  frame 
with  a  towel  swathe.  Extension  of  the  limbs  by  weight  and 
pulley  may  be  needed  in  addition  in  certain  cases  to  secure  im- 
mobilization of  the  fracture.     Wiring:  or  suture  of  the  fractured 


TREATMENT  OF  FRACTURES  OF  THE  PELVIS 


^33 


Fig.  122. — ^Fracture  of  crest  of  ilium  (Warren  Museum,  specimen  5938). 


i-'H'-^o-— 


Case  :  Fracture  of  the  crest  of  the  right  ilium  :  A,  Deloniiily  due  to  inward  displace- 
ment of  fractured  bone  ;  B,  posterior  lateral  view  (Porter). 


134 


FRACTURES    OF    THE    PELVIS 


Fig.  124. — ^Fracture  of  rami  of  pubes ;  fracture  and  separation  at  sacro-iliac  synchondrosis; 
much  displacement ;  bony  union  (Warren  Museum). 


Fig.  125. — Fractured  pelvis  :  on  the  right,  fracture  across  pubes  and  ischium  ;  on  the  left,  frac- 
ture involving  acetabulum  and  sacrosciatic  notch  (Warren  Museum,  specimen  3857). 


rupture;  of  the;  urethra 


'35 


bones  may  be  entertained  and  practised.     Wiring  is  indicated 
if  comminution  or  displacement  of  fragments  is  great. 

Visceral  Lesions. — Associated  with  fractures  of  the  pelvis 
there  may  be  lesions  of  important  viscera.  These  visceral  lesions 
render  fractures  of  the  pelvis  of  the  very  greatest  seriousness. 
The  trauma  causing  the  fracture  may  at  the  same  time  occasion 
a  rupture  of  the  kidney.     The  bladder,  urethra,  or  bowel  may 


Fig.  126. — Median  section  of  male  pelvis.  Note  the  close  relations  of  bladder  and  urethra  to  the 
symphysis  pubis.  Injury  to  the  symphysis  and  descending  rami  of  the  pubes  tan  readily  damage 
the  adjacent  urethra:  R,  Rectum;  Pr,  prostate;  B,  bladder;  S,  symphysis  pubis;  Sc,  scrotum;  P,  penis. 

also  be  ruptured.  The  shock  associated  with  a  fracture  of  the 
pelvis  is  great.  If  there  is  a  visceral  lesion,  the  primary  and 
secondary  shock  will  be  very  great. 

Rupture  of  the  Urethra. — This  is  sometimes  associated  with 
fracture  of  the  pelvis  (see  Fig.  126).  It  may  be  due  to  the  original 
trauma,  as  a  fall  or  blow  on  the  perineum,  or  it  may  be  caused 
by  bony  fragments  lacerating  the  urethra,  or  by  a  simple  sepa- 
ration of  the  symphysis  pubis.  Pain  at  the  seat  of  the  lesion, 
pain  upon  pressure  in  the  perineum,  retention  of  urine,  urethral 
hemorrhage,  swelling  in  the  perineum,  usually  exist.  Under 
these   circumstances   perineal    section   is    indicated    in   order   to 


136 


FRACTURES    OF   THE    PELVIS 


drain  the  wounded  area  and  the  bladder.  If  a  catheter  can  be 
passed  to  the  bladder  and  the  local  swelling  does  not  increase, 
permanent  or  interrupted  catheterization  is  indicated.  The 
patient  should,  however,  be  watched  carefully  for  the  signs 
of  extravasation  of  urine.     If  at  any  time  the  catheter  can  not 


Fig.  127. — Fracture  of  the  acetabulum.     The  head  of  the  femur  driven  into  the  pelvis.     Arrows  point 
to  the  lines  of  fracture  (J.  D.  Adams). 


be  passed,  operation  should  be  done  at  once,  as  in  the  first  in- 
stance. 

If  the  urethral  rupture  is  caused  from  above,  the  inferior 
surface  of  the  canal  may  be  intact.  If  so,  the  passage  of  the 
catheter  (if  difficult)  may  be  facilitated  by  depressing  the  in- 
strument slightly,  hugging  the  inferior  wall  of  the  urethra. 


RUPTURE    OF    THE    URETHRA 


137 


Fig.  12S. — Fracture  of  the  pelvis.     Rupture  of  urethra.     Note  the  (hsplacer!  ends  of  the  urethra.     Note 
the  false  passage  to  bladder  (H.  Cabot). 


Fi^.  120. — Fra<  turc  of  Ihc  [jdvis.     Rupture  of  urethra.     Note  the  possible  moljilization  of  the  urethra 

(H.  Cabot). 


138 


Fractures  of  the  pelvis 


If  the  urethra  in  its  perineal  or  scrotal  portions  is  destroyed  by 
a  fracture  of  the  pelvis,  if  there  is  an  actual  loss  of  substance, 


Fig.  130. — Fracture  of  the  pelvis.     Rupture  of  urethra.     Note  displacement  of  fractured  bone  with 
separation  at  the  symphysis  (H.  Cabot). 


Fig.  131. — Fracture  of  the  pelvis.     Rupture  of  lu-ethra.     Note  sutures  placed  to  unite  much  mobilized 

urethra  (H.  Cabot). 


H.  Cabot  has  shown  that  the  principle  of  mobilizing  the  urethra 
may  be  applied  with  good  results  in  restoring  the  canal.     The 


RUPTURE  OF  the;  urinary  bladder  139 

mobilization  may  be  carried  farther  than  has  been  hitherto 
thought  possible.  The  accompanying  plates  illustrate  a  case  in 
point.  In  all  plastic  work  tension  of  parts  is  to  be  avoided.  This 
demonstration  by  Cabot  of  the  possibiHty  of  great  mobilization 
of  the  urethra  makes  a  suture  of  the  urethra  without  destructive 
tension  successful. 

Rupture  of  the  Urinary  Bladder. — This  may  be  either  extra- 
or  intraperitoneal.  When  the  bladder  is  empty,  it  is  low  down 
in  the  pelvis  and  can  be  injured  only  by  a  fracture  of  the  pelvis. 
The  rupture  of  the  bladder  due  to  fracture  of  the  pelvis  is  usually 
extraperitoneal  and  it  is  situated  on  its  anterior  surface. 

On  account  of  the  fracture  the  patient  can  not  walk.  Rup- 
ture of  the  bladder  itself  might  occasion  inability  to  walk,  at 
least  any  long  distance.  There  is  great  hypogastric  pain,  fre- 
quent desire  to  micturate,  and  inability  to  pass  urine.  A  few 
drops  of  bloody  fluid  escape  from  the  meatus.  Dullness  may 
be  present  in  the  lower  abdomen  and  loins.  Soon  after  the 
accident,  if  not  immediately,  there  is  great  prostration.  Evi- 
dences of  shock  are  seen  in  the  pallor  of  the  face,  the  anxious 
expression,  the  feeble  pulse,  the  cold,  clammy  skin,  and  feeble 
voice.  The  abdomen  becomes  distended,  the  temperature  rises, 
and  delirium,  coma,  and  death  follow  with  certainty  unless  op- 
erative interference  has  relieved  the  condition  at  a  very  early 
hour  after  the  accident.  The  patient  dies  from  shock,  hemor- 
rhage, or  septic  peritonitis. 

If  the  patient  is  seen  soon  after  the  accident,  before  unto- 
ward symptoms  have  appeared,  and  has  not  micturated  for 
some  little  time,  he  should  be  catheterized.  An  empty  bladder 
will  be  found  or  a  small  amount  of  bloody  fluid  will  be  with- 
drawn, which  rather  confirms  the  other  evidences  of  ruptured 
bladder.  If  there  is  doubt  as  to  the  rupture  of  the  bladder, 
the  symptoms  should  be  watched.  The  symptoms  of  rupture 
may  be  masked  or  delayed  by  the  associated  lesions.  The 
urine  may  be  tinged  with  blood  because  of  a  contusion  of  the 
bladder.  The  catheter  may  be  passed  through  the  bladder- 
wall,  and  be  felt  to  enter  the  abdominal  cavity,  evacuating 
bloody  fluid.  All  fluid  having  been  removed  from  the  bladder, 
if  a  measured  amount  of  sterile  water  is  injected  into  it,  and  all 


140  FRACTURES    OF    THE    PELVIS 

that  was  injected  does  not  return,  presumption  of  rupture  of 
the  bladder  is  very  great.  Under  such  circumstances  the  dull 
area  in  the  groins  and  lower  abdomen  of  extraperitoneal  rupture 
will  be  increased. 

Exploratory  laparotomy  should  be  done,  and  if  the  extrav- 
asation proves  to  be  extraperitoneal,  drainage  of  this  area  is 
demanded.  Temporarv  drainage  of  the  bladder,  either  urethral 
or  through  perineal  section,  will  be  needed  to  permit  healing 
of  the  bladder  wound.  The  bladder  wound  is  usually  inacces 
sible  to  suture  in  these  cases. 

Prognosis. — A  guarded  prognosis  should  always  be  given 
in  any  case  of  fracture  of  the  pelvis.  Fractures  of  the  iliac 
crest  ordinarily  recover  in  a  few  weeks.  In  fractures  complicated 
by  rupture  of  the  bladder  or  bowel  the  prognosis  is  extremely 
grave. 


CHAPTER  VII 

FRACTURES  OF  THE  CLAVICLE 

Anatomy. — The  upper  surface  of  the  clavicle  is  subcutaneous 
throughout  its  whole  length  (see  Fig.  134).  The  acromioclavicular 
joint  is  at  its  outer  end.  The  sternoclavicular  joint  is  at  its  inner 
end.  The  clavicle  lies  in  a  muscular  plane  made  up  of  the 
trapezius  and  sternocleidomastoid  muscles  above,  and  the  deltoid, 


Acromial 
end. 

■ 

Right 
clavicle. 

^^^H 

^1 

■jjHH 

^^^^^K    ^^^^H 

^H 

^^^^^^Hr   ^^^1 

^H^^H 

^^^^^BP' '  j^^H 

^^B.^1 

^^^^^1 

Sternal 

^I^^^B^M^^^^l 

^^^^^^K  \^H 

P^^^l 

end. 

^B^B 

^B 

Left 
olavicle 


Fig.  132. — ^Upper  surfaces  of  the  right  and  left  clavicles. 

pectoralis  major,  and  subclavius  muscles  below  (see  Fig.  134).  It 
is  important  to  recognize  the  situation  and  the  direction  of  the 
acromioclavicular  joint  in  order  to  discriminate  between  a  frac- 
ture of  the  outer  end  of  the  clavicle  and  one  of  the  acromial 
process.  It  is  likewise  important  intelligently  to  palpate  the 
normal  shoulder,   to  determine  that  the  acromial  process  does 

141 


142  FRACTURES    OF   THE    CIvAVICLE 

not  form  the  outer  limit  of  the  shoulder,  but  that  it  is  formed 
by  the  greater  tuberosity  of  the  humerus. 

Symptoms. — The  common  seat  of  fracture  is  in  the  middle 
third  of  the  bone  (see  Figs.  135-138  inclusive).  The  shoulder, 
having  lost  the  support  of  the  clavicle,  falls  forward  and  drops 
inward,  consequently  the  outer  fragment  that  moves  with  the 
shoulder  drops  below  the  inner  fragment  and  overlaps  it  in  front. 
The  inner  fragment,  having  attached  to  it  the  sternocleidomastoid 
muscle  and  being  comparatively  free  to  move,  is  drawn  slightly 


Acromial  end. 


Left  clavicle.  W^^^y  ^^Hl  y'^'-'^^yf^  ^'^^^      ^^^B  ^'^^'^  clavicle. 


Sternal  end. 


Fig.  133. — Under  surfaces  of  the  right  and  left  clavicles. 

upward.  The  attitude  of  the  patient  is  characteristic  (see  Fig. 
139):  he  stands  with  the  head  inclined  to  the  injured  side, 
thus  relaxing  the  pull  of  the  sternocleidomastoid  muscle  upon 
the  inner  fragment.  The  shoulder  upon  the  side  fractured  is 
depressed;  the  elbow  and  forearm  upon  this  same  side  are  sup- 
ported by  the  well  hand.  This  is  the  attitude  of  greatest  com- 
fort. The  shoulder — i.  e.,  the  space  between  the  base  of  the 
neck  and  the  greater  tuberosity  of  the  humerus — is  shortened 
upon  the  injured  side  (see  Fig.  151).     If  the  fracture  lies  within 


fracture;  of  the;  clavicle  in  childhood 


143 


the  limit  of  the  coracoclavicular  ligament  or  outside  of  it,  there 
will  be  no  appreciable  displacement.  The  diagnosis  under  these 
circumstances  will  be  difficult.  Localized  pain  and  the  dis- 
ability of  the  arm  will  suggest  the  lesion  present. 

Fracture  of  the  Clavicle  in  Childhood. — More  than  one-third 
of  all  fractures  of  the  clavicle  occur  in  children  under  five  years 
of  age.  A  trivial  injury  is  the  usual  cause  of  the  fracture.  A 
little  child  may  fall  from  a  low  chair  or  out  of  bed  and  fracture 

Coracoid.     Clavicle. 


Acromion. 
Great  tuberosity 


-Trapezius. 

-Sternocleido- 
mastoid. 


Pectoralis  major. 


Fig.  134. — Muscles  arising  iiuin  and  allachcd  to  the  clavicle,  showing  the  muscular  plane  in 
which  the  clavicle  lies. 


the  bone.     The  fracture  is  almost  always  incomplete  or  green- 
stick. 

The  child  cries  upon  moving  the  arm.  Tifting  the  child  by 
placing  the  hands  in  the  armpits  causes  pain.  The  arm  of  the 
injured  side  may  be  used  as  naturally  as  the  other  or  there  may 
be  some  disability,  perhaps  simply  a  disinclination  to  use  the 
arm.  If  the  fracture  is  greenstick,  a  tender  swelling  appears 
at  the  seat  of  the  fracture.  If  the  fracture  is  complete,  an  un- 
evenness  will  be  felt  at  the  seat  of  fracture  according  to  the 
amount   of   displacement.     The    displacement    is   usually   slight 


144 


Fractures  of  the  clavicle 


in  childhood.  The  characteristic  attitude  seen  m  adults  (see 
Fig.  139)  is  much  less  marked  in  children,  and  if  the  fracture 
is  greenstick,  there  is  no  tilting  of  the  head  and  depression  of 
the  shoulder.  If  the  child,  as  so  often  occurs,  persistently  holds 
the  head  so  that  a  careful  examination  is  impossible,  then  it  is 
best  to  place  the  child  on  its  back,  and  while  its  legs  and  arms 
are  held  firmly,  the  head  and  shoulder  may  be  gently  and  gradu- 
ally separated.     The  examination  can  then  be  completed. 

Treatment  in  Adults. — The  displacement  should  be  corrected 
and    the    corrected    position    maintained    (see    Figs.    141,    142). 


Seat  of  fracture. 

Fig.  135- — Fracture  at   the   middle   of  the 
clavicle  (Warren  Museum). 


Seat  of  fracture. 

Fig.  136.— Fracture   at  the   middle   of  the 
clavicle  (Warren  Museum). 


Seat  of  fracture. 


Fig.  137. — Fracture  of  the  clavicle   at  the 
outer  end.     No  displacement. 


Fig.  138. — Fracture  of  the  clavicle, 
showing  considerable  deformity  (Warren 
Museum). 


The  indications  are  to  carry  the  shoulder,  and  with  it  the  outer 
fragment,  upward,  outward,  and  backward. 

TJie  Recumbent  Treatment. — The  displacement  is  most  satis 
factorily  corrected  by  the  patient  lying  recumbent  upon  a  firm 
mattress.  The  weight  of  the  shoulder  in  this  position  does  not 
impede  reduction,  as  in  the  upright  position,  but  assists  it.  A 
firm  and  small  pillow  should  be  placed  between  the  shoulders. 
The  shoulders  fall  backward  of  their  own  weight  over  the  pillow 
carrying  the  outer  fragment  backward  at  the  same  time.  Pad- 
ding of  the  fragments  of  the  clavicle,  the  application  of  pres- 
sure to  the  elbow,  may  be  more  satisfactorily  accomplished  in 
the  recumbent  than  in  the  upright  position.  Union  ordinarily 
occurs   within   three   weeks.     At   the   time  of  union   or  shortly 


Fig   139- —Case  :  Comminuted  fracture  of  the  left  clavicle.    Attitude  characteristic  ;  deformity 
visible;  wired  (Mixter). 


Fig.  140-  ^A  fracture  of  the  clavicle  at  A,  the  usual  situation,  would  result  in  consider- 
able displacement  of  the  inner  fragment.  A  fracture  situated  within  x  y  is  usually  little  dis- 
placed :  X,  Conoid  ligament ;  y,  trapezoid  ligament ;  z,  coraco-acromial  ligament ;  c,  acromion; 
b,  coracoid  process ;  e,  scapula  ;  d,  head  of  humerus  ;  g,  long  tendon  of  the  biceps. 


10 


145 


Fig.  141.— Fracture  of  the  clavicle.  Method  of  correction  of  falling  inward  and  downward 
of  shoulder,  in  overriding  of  fragments  previous  to  the  application  of  the  modified  Sayre 
dressing. 


Fig.  142.— Fracture  of  the  clavicle.    Same  as  figure  141.    Posterior  view,  showing  extreme 
backward  position  of  shoulders. 

146 


Fig.  143. — Fracture  of  the  left  clavicle.  Mod- 
ified Sayre  dressing.  Towel  circular  of  upper  arm 
held  by  adhesive  plaster.  Adhesive-plaster  strap 
ready. 


Fig.  144. — Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  ap- 
plied. Shoulder  carried  backward. 
Fixed  point  established  above  middle 
of  humerus. 


Fig.  I4S- — Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  applied. 
Second  adhesive-plaster  strap  being  ap- 
plied. Hole  in  plaster  for  olecranon  visi- 
ble. Note  pad  for  wrist  and  folded  towel 
protecting  skin  of  arm  and  chest. 


lig.  146. — Fracture  of  the  left  clavicle. 
First  and  second  adhesive-plaster  straps 
applied.  Pad  in  left  hand.  Shouldei 
pulled  backward  and  elevated. 


147 


148 


FRACTURES    OF   THE    CLAVICLE 


after  the  patient  may  be  allowed  up  with  a  simple  retentive 
dressing,  a  sling,  and  a  swathe.  The  bed  treatment  is  hard  to 
enforce  because  the  fracture  is  the  cause  of  so  little  real  per- 
manent disability.  If  there  is  much  displacement  and  de- 
formity can  not  be  corrected  and  held  properly,  the  bed  treat- 
ment is  indicated.  In  the  simultaneous  fracture  of  both  clavicles 
the  recumbent  bed  treatment  is  the  best  (see  Operative  Treat- 
ment of  Fracture  of  the  Clavicle). 


Fig.  147. — ^Fracture  of  the  right  clavicle. 
Modified  Sayre  dressing.  Posterior  view. 
Shoulder  elevated  and  pulled  backward. 
Folded  towel  seen  in  axilla  for  protection 
to  skin. 


Fig.  14S. — Fracture  of  the  clavicle.  Meth- 
od ot  application  of  a  Velpeau  bandage.  Note 
the  order  and  direction  of  the  turns  i,  2,  3, 
4,  and  5.  Note  position  of  the  forearm  and 
arm  of  the  uninjured  side. 


The  Modified  Sayre  Dressing. — The  shoulder  and  arm  are 
unwieldy  in  adults.  It  is,  therefore,  necessary  in  treating  a 
fracture  of  the  clavicle  by  an  ambulatory  method  to  secure  a 
very  firm  hold  upon  the  shoulder  in  order  to  maintain  the  cla- 
vicular fragments  in  a  good  position. 

The  modified  Sayre  adhesive-plaster  dressing  is  the  best. 
It  is  applied  as  follows:  Provide  three  strips  of  adhesive  plaster, 
four  inches  wide,   and  long  enough  to  extend  once  and  a  half 


thR  modified  sayre  dressing 


149 


around  the  body.  The  skin  surfaces  that  are  to  come  in  contact — 
namely,  the  axilla  and  chest  and  forearm — are  separated  by 
compress  cloth  and  powder.  A  dressing  towel,  folded  like  a 
cravat,  is  snugly  pinned  high  up  about  the  upper  arm  (see  Fig. 
143).  This  towel  may  be  held  neatly  by  a  strip  of  adhesive 
plaster.  One  end  of  the  first  adhesive  strap  is  fastened  loosely 
about  the  towel -protected   arm  with   a   safety-pin.      While   an 


Fig.  149. — Fracture  of  the  clavicle  and  subluxation  of  the  acromioclavicular  joint.  Notice 
elevation  of  shoulder  by  pressure  on  the  flexed  elbow  and  counterpressure  on  the  clavicle  by 
a  bandage  and  a  pad  (X)  placed  internal  to  the  acromioclavicular  joint. 


assistant  holds  the  shoulder  well  back  the  arm  is  carried  back- 
ward, and  held  by  the  fastening  of  the  first  adhesive  strap  about 
the  body  (see  Fig.  144).  This  affords  a  fixed  point  at  the  middle 
of  the  upper  arm.  The  second  strap,  with  a  hole  in  it  to  receive 
the  point  of  the  elbow,  is  started  upon  the  posterior  surface 
of  the  injured  shoulder  (see  Fig.  145)  and  carried  under  the 
elbow  of  the  injured  side  and  over  the  well  shoulder  (see  Fig. 


I50 


FRACTURES    OF    THE    CLAVICLE 


146).  The  forearm  is  flexed,  and  rests  upon  the  chest.  In 
applying  this  second  strap  the  shoulder  is  raised  and  the  elbow 
is  carried  forward,  thus  forcing  the  shoulder  slightly  upward 
and  backward  of  the  fixed  point  used  as  a  fulcrum  (see  Fig.  147. 
A  third  strap  may  be  placed  around  the  trunk  and  arm  to  steady 
all  in  good  position.  Over  this  dressing  may  be  put  a  Velpeau 
bandage  for  the  comfort  of  the  support  which  it  affords  (see 
Fig.  148).      The  adhesive  plaster  may  be  covered  with  bits  of 


Fig.  150- — Double  fracture  of  the  clavicle.  Note  the  displacement  of  the  fragments.  A,  acro- 
mion ;  H,  humerus  ;  G.  glenoid  ;  C.  coracoid  process.  C.  C.  C.  each  on  a  fragment  of  the  clavicle. 
The  arrows  point  to  the  sites  of  the  fractures  (M.  G.  H.  series). 


gauze  bandage,  in  part  to  protect  the  skin  from  undue  chafing, 
sufficient  plaster  surface  remaining  uncovered  to  prevent  the 
straps  from  slipping.  Occasionally,  pads  (see  Fig.  149)  upon 
the  clavicle  may  be  used  to  correct  the  deformity,  but  the  bone 
is  so  subcutaneous  that  the  skin  can  not  bear  great  pressure 
without  damage.  If  pads  are  used,  they  must  receive  frequent 
inspection. 

Treatment  in  Children. — The  skin  of  the  child  must  be 
protected  by  powder  and  careful  drying  before  the  arm  is  done 
up.  If  it  is  a  greenstick  fracture  and  there  is  slight  deformity, 
this  deformity  should  be  corrected  by  pressure  with  the  thumbs. 
An  anesthetic  should  be  used.  After  the  deformity  is  corrected 
and  in  cases  without  deformity  it  is  necessary  simply  to  restrain 
the  movements  of  the  arm  for  two  weeks.  This  is  best  accom- 
plished by  a  cotton  swathe  about  the  body  and  upper  arm, 
held  by  straps  over  the  shoulders  and  by  a  cravat  sling.     In 


TREATMENT    IN    CHILDREN 


151 


warm  weather  and  also  in  cool  weather,  for  that  matter,  the 
arm  is  to  be  inspected  frequently,  as  often  as  every  third  day, 
when  all  the  dressings  are  removed,  the  parts  bathed  with  soap 
and  warm  water,  powdered,  and  the  simple  retentive  dressing 


Fig.  151. — Fracture  of  the  right  clavicle.     Shortening  of  the  shoulder. 


reapplied.  With  this  care  only  can  chafing  be  avoided.  If 
it  is  a  complete  fracture,  the  modified  Sayre  adhesive-plaster 
dressing  should  be  used  as  in  adults.  The  skin  is  to  be  carefully 
protected,  and  the  dressing  most  assiduously  watched.  It 
requires  but  forty-eight  hours  for  great  chafing  to  occur  with 
the  resulting  discomfort  and  the  slow  healing  which  often  re- 
sults. If  union  is  firm  after  two  weeks  or  two  weeks  and  a  half, 
the  plaster  dressing  should  be  removed  and  the  shoulder  put 
up  in  a  simple  retentive  swathe  and  sling,  at  first,  inside  the 
clothes;  after  three  weeks,  outside  the  clothes.  In  very  active 
children  the  sling  should  not  be  removed  until  four  weeks  have 
elapsed.  Massage  should  be  given  to  the  forearm,  elbow,  and 
shoulder  alter  the  first  week,  together  with  passive  motion  of 


152 


FRACTURES    OF   THE    CLAVICLE 


the  elbow.  In  both  children  and  adults  the  adhesive-plaster 
dressing  should  be  reapplied  at  least  once  every  ten  or  twelve 
days.  If  the  dressing  chafes  or  slips,  it  may  need  more  frequent 
renewal. 

Prognosis. — Useful  arms  and  shoulders  usually  result  after 
fracture  of  the  clavicle.  Almost  all  complete  fractures  of  the 
clavicle  with  displacement  of  fragments,  after  repair  has  taken 
place,  show  unmistakable  evidences  of  deformity  at  the  seat  of 
fracture,  of  shortening  of  the  width  of  the  shoulders,  and  in 
many  instances  in  children  of  a  slight  lateral  deformity  of  the 


Fig. 


152. — Fracture  of  right  clavicle  showing  amount  of  callus  present  when  union  was  com- 
pleted.   The  deformity  from  this  callus  entirely  disappeared  after  several  weeks. 


spinal  column  (see  Fig.  151).  Fractures  within  the  coraco- 
clavicular  ligament  having  little  displacement  of  fragments 
show  no  resulting  deformity.  Very  great  deformity  does  not 
preclude  a  useful  arm.  An  ununited  fracture  of  the  clavicle 
is  unusual;  it  may  exist  and  cause  no  especial  inconvenience; 
it  may  be  unknown  to  the  patient.  An  ununited  fracture  of 
the  clavicle  with  considerable  callus-formation  may  simulate 
malignant  disease  of  the  bone.  Laboring  men  are  rarely  kept 
from  their  work  more  than  two  months.  Fractures  of  the  clavicle 
in  young  children,  if  carefully  treated,  should  unite  with  prac- 
tically no  deformity  or  disability.  Greenstick  or  incomplete 
fractures  may  show  a  general  bowing  of  the  whole  bone,  which 
it  has  been  impossible  to  correct. 


operative;  treatment 


153 


Operative  Treatment. — In  recent  fractures:  If  there  is  great 
displacement  which  can  not  be  held  reduced,  if  sharp  fragments 
threaten  vessels  or  nerves,  if  there  is  pressure  upon  either  nerves 
or  blood-vessels,  if  the  fracture  is  a  comminuted  one,  and  if  the 


Fig.  153. — Man  twenty-four 
years  old.  Left  clavicle  frac- 
tured by  rolling  log.  Immediate 
paralysis  of  the  upper  extremity. 
Seven  months  subsequently  clav- 
icle callous  resected.  No  subse- 
quent improvement.  The  upper 
part  of  the  (trapezius  intact.  Note 
attitude  of  upper  extremity,  seat 
of  fractiure  pointed  to  by  arrow, 
atrophy  of  shoulder  muscles, 
upper  arm  and  1  ower  arm  mus- 
cles (C.  E.  Briggs). 


i 


bone  is  fractured  in  two  or  more  places  (multiple  fractures),  it 
is  wise  to  consider  operative  measures.  The  fragments  can  be 
exposed,  replaced,  and  held  in  position  by  suturing.  It  is  wise 
in  suturing  the  fracture  of  the  clavicle  to  use  if  practicable  an 
absorbable  suture  material  rather  than  silver  or  aluminum  bronze 
wire.  Good  results  follow  this  treatment.  After  operation  for 
fracture  of  the  clavicle  a  simple  retentive  dressing  of  a  swathe 


154 


FRACTURES   OF  THE    CLAVICLE 


and  cravat  sling  will  be  needed.     It  should  be  worn  for  at  least 
three  weeks. 


Fig.  154. — Posterior  view  of  Fig.  153.     Note  position  of  the  upper  extremity  and  the  atrophy. 

In  Ununited  Fractures. — If  the  cause  of  delayed  union  of  the 
fracture  is  a  misplaced  bony  fragment,  an  interposed  strip  of 
fascia  or  periosteum,  or  an  interposed  subclavius  muscle,  opera- 
tive interference  may  be  undertaken  with  a  reasonable  expec- 
tation of  securing  a  good  result.  If,  on  the  other  hand,  nonunion 
has  existed  for  a  long  period  (a  year  or  more),  it  is  highly  probable 
that  the  ends  of  the  fragments  will  be  so  attenuated  that  re- 
freshing these  ends  for  suture  would  shorten  the  fragments  to 
such  an  extent  that  suture  would  be  impossible. 


CHAPTER  VIII 

FRACTURES  OF  THE  SCAPULA 

The  spine  and  acromial  process,  the  coracoid  process,  and 
the  vertebral  and  axillary  borders  of  the  scapula  can  be  palpated 
with  comparative  accuracy.  Fracture  of  the  scapula  is  of  rather 
unusual  occurrence,  and  always  follows  great  violence  (see  Figs. 

155,   156,  157)- 

Fracture  of  the  body  of  the  scapula  is  transverse  between 


Coracoid  process. 


Glenoid  cavity. 


Acromion  process. 


Spine. 


Fig.  155. — Normal  scapula.     Axillary  view. 

the   axillary  and   vertebral   borders  or  comminuted  in  various 
directions  (see  Figs.  158,  159). 

Crepitus,  abnormal  mobility,  local  swelling,  and  tenderness 
are  present.  Pain  is  felt  upon  attempting  to  abduct  the  arm. 
It  may  be  impossible  to  raise  the  arm  to  the  head. 

155 


Venter. 


Fig.   156. — Ivlormal  scapula.     Ventral  view. 


Spine. 


Axillary 
border. 


Fig.  157- — Normal  scapula.     Dorsal  view. 
156 


FRACTURE    OF    THE    NECK    OF    THE    SCAPULA  157 

Fracture  of  the  Acromial  Process  of  the  Scapula. — The 
epiphysis  of  the  acromion  unites  with  the  scapula  about  the 
twentieth  year.  If  there  is  a  fracture  present,  and  not  a  sepa- 
ration of  the  epiphysis,  which  sometimes  occurs,  the  line  of 
fracture  is  ordinarily  outside  the  acromioclavicular  joint.  A 
fracture  may  occur  through  the  acromion  nearer  to  the  spine 
of  the  scapula. 


Fig.    i^g. — Fracture  of   the  body  of  the  scapula.     Bony  union  with  moderate   displacement 
(Warren  Museum,  specimen  8111). 


Localized  pain,  swelling,  and  tenderness,  and  a  flattening  of 
the  shoulder  are  present.  Crepitus  may  at  times  be  felt.  If 
the  fracture  is  inside  the  acromioclavicular  joint,  the  flattening 
of  the  shoulder  will  be  considerable.  The  head  of  the  humerus 
is  felt  in  the  glenoid  cavity,  thus  ruling  out  a  dislocation. 

Fracture  of  the  neck  of  the  scapula  is  most  unusual.  If 
present,  it  may  be  mistaken  for  a  dislocation  of  the  humeral 
head. 


1^8  FRACTURES    OF    THE    SCAPULA 

The  acromial  process  is  prominent.  The  upper  arm  is  length- 
ened. On  lifting  the  arm  forcibly  upward  with  the  elbow  flexed, 
the  deformity  is  corrected,  and  crepitus  is  detected.  The  de- 
formity recurs  if  this  upward  pressure  is  removed.  The  reap- 
pearance of  the  deformity  and  the  crepitus  serve  to  distinguish 
this  injury  from  a    dislocated  shoulder.     In  a  thin  person  pal- 


Fig.   159. — Multiple  fractures  of  scapula.     Railroad  accident.     Man,  forty-three  years  of  age. 
Lived  one  day  (Warren  Museum,  specimen  6028). 


pation  of  the  edges  of  the  glenoid  cavity  itself  will  prove  rather 
satisfactory;  the  crepitus  and  abnormal  mobility  can  thus  be 
more  accurately  located. 

Treatment  in  General. — Immobilization  of  the  whole  upper 
extremity,  except  the  forearm  and  hand,  is  necessary.  lyocalized 
pressure  may  assist  in  retaining  fragments  in  place. 


TREATME^NT   Olf    FRACTUREJS    OF    THE;    SCAPULA  159 

If  there  is  fracture  of  the  body  of  the  scapula,  the  forearm 
should  be  flexed  to  a  right  angle  and  held  in  a  sling.  The  skin- 
surfaces  coming  in  contact  should  be  protected  by  powder  and 
compress  cloth.  A  swathe  of  cotton  cloth  should  be  fastened 
about  the  upper  arm  and  trunk.  If  the  cloth  swathe  is  not 
sufficient  to  hold  the  scapula  steady,  a  swathe  of  adhesive  plaster 
should  be  used,  broad  enough  to  extend  from  the  acromion  to 
the  elbow. 

Fracture  of  the  Acromial  Process:  The  skin-surfaces  must 
first  be  protected  from  chafing.  The  forearm  being  flexed,  pres- 
sure upward  should  be  made  upon  the  elbow,  so  as  to  lift  the 
arm  and  relax  the  pull  on  the  small  acromial  fragment.  At  the 
same  time  counterpressure  is  made  upon  the  inner  fragment  and 
incidentally  upon  the  inner  shoulder  (see  Fig.  149).  This  pres- 
sure and  counterpressure  will  hold  the  part  reduced.  The  ban- 
dage must  be  inspected  frequently  each  day,  in  order  to  detect 
and  to  relieve  too  great  pressure  upon  the  elbow  and  bony  parts 
of  the  shoulder. 

Union  will  take  place  in  from  three  to  four  weeks.  It  is  ex- 
tremely difficult  to  maintain  the  reduction  of  the  fragment  of 
the  acromion  by  any  apparatus.  The  one  previously  suggested 
meets  the  indications  better  than  any  other.  Massage  will 
materially  assist  in  hastening  the  absorption  of  blood  and  will 
relieve  pain.  No  very  great  functional  disability  results  if  union 
occurs  with  bony  displacement. 


CHAPTER  IX 
FRACTURES  OF  THE  HUMERUS 

FRACTURES  OF  THE  UPPER  END  OF  THE  HUMERUS 
Anatomy. — The  clavicle  may  be  felt  throughout  its  entire 
length  from  sternum  to  acromion.  The  acromial  process  of 
the  scapula  articulates  with  the  outer  end  of  the  clavicle.  This 
acromioclavicular  joint  has  an  anteroposterior  direction,  and 
n  the  line  of  this  joint  is  continued  anteriorly,  it  will  pass  down 


Head  and  articular 
surface. 


Surgical  neck. 


L 
Fig.    i6o. — Upper  enil  ot  luimerus.     Inner  view. 

the  front  of  the  upper  arm  (see  Fig.  162).  The  outer  edge  of 
the  acromion  is  continuous  downward  and  backward  with  the 
spine  of  the  scapula.  The  great  tuberosity  of  the  humerus  pro- 
jects beyond  the  acromial  process,  and  is  covered  by  the  deltoid 
muscle.  The  point  of  the  shoulder  itself  is  made  by  the  humerus 
and  not  by  the  acromion  (see  Figs.  162,  163). 

160 


ANATOMY 


i6x 


Anatomical  neck. 


Great  tuberosity. 


z'      L 


f   •> 


Surgical  neck.. 


Fig.  i6i. — Upper  end  of  humerus.     Anterior  view. 


Clavicle. 


Bicipital 
groove. 


Spine  of 
scapula. 


Supraspinous 
fossa. 


Fig.  162. — View  of  bones  of  the  shoulder  from  above.  Notice  acromioclavicular  joint,  its 
relations  to  bicipital  groove  and  coracoid  process.  The  point  of  the  shoulder  is  made  by  the 
great  tuberosity  of  the  humerus. 


l62 


FRACTURES    OF    THE    HUMERUS 


Examination  of  the  Shoulder. — The  uninjured  shoulder 
should  be  examined  before  the  injured  shoulder.  In  injuries 
doubtful  in  character,  associated  with  much  swelling  of  the 
shoulder,  and  which  are  painful  upon  gentle  manipulation,  the 
examination  should  be  made  with  the  aid  of  an  anesthetic.  Great 
swelling  suggests  great  trauma ;  absence  of  all  swelling  appreciable 
to  the  eye  suggests  slight  trauma. 

For  the  examination  the  patient  should  be  seated  upon  a 
rather  high  stool,   so  that  the  shoulder  comes  to  an  easy  level 

Clavicle. 


Acromion. 


Great  tuberosity. 
Coracoid. 


Fig.  163. — Relations  of  bones  to  surfaces  of  shoulder  region.  Great  tuberosity  of  humerus 
projects  beyond  the  acromial  process  of  scapula.  Relations  of  coracoid  to  clavicle  and  head 
of  humerus  (compare  with  Fig.  i6y). 


for  manipulation.  The  shoulder  should  be  grasped,  so  that  the 
head  of  the  humerus  can  be  felt  between  the  fingers  and  thumb 
of  one  hand  pressed  under  the  spinous  and  acromial  processes. 
The  other  hand  should  grasp  the  flexed  elbow  firmly,  in  order 
to  make  the  necessary  movements  at  the  shoulder- joint  (see 
Fig.  164).  If  the  head  of  the  humerus  is  intact  and  in  its  normal 
place,  it  will  be  felt  to  move  with  the  shaft  of  the  humerus,  as 
upon  the  uninjured  side.  All  the  normal  movements  of  the 
shoulder-joint  should  be  made  passively  and  actively — namely, 
the  movements  of  abduction,  adduction,  forward  and  backward 
swing,   and    rotation    (see   Figs.    165,    166,    167).     Those   move- 


Fig.   164. — Examination  of  shoulder.     Method  of  palpating  head  of  humerus  with  thumb  and 
fingers.     Elbow  grasped  by  other  hand. 


Fig.  165. — Examination  of  shoulder.     Movements  of  the  shoulder.     Normal  maximum  abduc- 
tion.    Notice  method  of  grasping  head  of  liumerus. 
163 


164 


FRACTURES    OF    THE    HUMERUS 


ments  which  are  painful  and  Hmited  should  be  carefully  noted. 
Unless  the  normal  individual  standard  of  movement  is  known, 
as  determined  by  examination  of  the  well  shoulder,  there  can 
be  no  definite  interpretation  of  the  conditions  existing  in  the 
injured    shoulder.     The    condition    of    the    circulation    and    the 


Fig.    166. — ^Examination  of  shoulder.     Maximum  adduction.     The  bend  of  the  elbow,  when 
the  forearm  is  flexed  to  a  right  angle,  comes  to  the  median  line  of  trunk. 


presence  of  paresis  or  paralysis  in  the  limb  should  be  observed. 
The  shaft  of  the  humerus  should  be  measured:  the  measurement 
best  taken  is  the  distance  between  the  edge  of  the  acromial  pro- 
cess and  the  external  condyle  of  the  humerus.  The  patient 
should  be  seated  with  the  elbow  at  the  side  if  possible,  and  flexed 
to  a  right  angle  (see  Fig.  168).  The  forearm  should  rest  on 
the  thigh  of  the  same  side.  The  direction  of  the  long  axis  of  the 
humerus  should  be  carefully  noted. 

The  coracoid  process  of  the  scapula  in  all  injuries  to  the  shoulder 
should  be  palpated,  for  a  knowledge  of  its  position  assists  in 
locating  the   head  of  the  humerus  intehigently   (see  Fig.    169). 


DIAGNOSIS 


165 


The  examiner  should  stand  in  front  of  the  patient,  and  place 
the  left  hand  upon  the  right  shoulder  and  the  right  hand  upon 
the  left  shoulder,  the  hands  being  open.  The  thumb  should 
fall  below  the  clavicle  a  full  finger's-breadth,  when  the  end  of  the 
thumb  will  touch  the  coracoid.     It  is  generally  possible  to  feel 


Fig.    167. — Examination   of    slioulder.      Maximum    outward    rotation. 

examining  hands. 


Notice    position  of 


the  coracoid  even  in  very  stout  people  and  when  much  swell- 
ing is  present. 

Diagnosis. — It  is  sometimes  impossible  to  determine  the 
exact  lesion  following  an  injury  to  the  shoulder.  Anesthesia 
and  the  Rontgen  ray  are  invaluable  aids  to  diagnosis.  It  is  of 
the  first  importance  to  know  whether  the  head  of  the  humerus 
is  in  the  glenoid  cavity  or  whether  it  is  dislocated;  this  is  deter- 
mined by  palpation  and  by  noting  the  direction  of  the  long  axis 
of  the  humerus.  It  is  next  in  importance  to  learn  whether 
there  is  a  fracture  of  the  humerus.  If  the  humeral  head  rotates 
with  the  shaft,  there  is  probably  no  fracture  unless  there  is  one 
with  impaction  or  one  of  the  great  tuberosity.     If  the  humeral 


i66 


FRACTURKS    OF   THE    HUME^RUS 


head  does  not  rotate  with  the  shaft,  then  there  is  a  fracture.  If 
crepitus  is  present,  the  diagnosis  is  confirmed.  In  elderly  people 
a  simple  contusion  of  the  shoulder  from  a  fall  may  occasion  so 
great  a  hematoma  without  any  other  damage  that  one  may  be  in 
considerable  doubt  whether  or  not  a  fracture  exists.  The  vessels 
in  the  old  are  easily  lacerated  and  great  extravasations  may  occur 
and  be  very  misleading.  After  injury  to  the  shoulder  the  follow- 
ing fracture  lesions  may  be  present,  and  are  to  be  considered : 


Fig.  i6S. — Method  of  measur- 
ing the  length  of  the  shaft  of  the 
humerus  from  the  acromial  pro- 
cess to  the  external  condyle. 


Fig.  169. — Examination  of  shoulder.  Palpating 
the  coracoid  processes.  Note  the  position  of  the  hands 
and  thumbs. 


Fracture  of  the  anatomic  neck  of  the  humerus. 
Separation  of  the  upper  humeral  epiphysis. 
Fracture  of  the  surgical  neck  of  the  humerus. 
Fracture  of  the  great  tuberosity  of  the  humerus. 
Fracture  of  the  glenoid  of  the  scapula. 


In  any  one  of  these  instances  a  dislocation  of  the  humeral 
head  from  the  glenoid  cavity  may  exist  and  complicate  the  case 
(see  page   186). 

Simple  Dislocation  of  the  Humeral  Head,  Subcoracoid 
(see  Fig.  170). — The  attitude  is  characteristic:  the  affected  arm 


FRACTURE    OF    THE    ANATOMICAL    NECK 


167 


is  held  flexed,  with  the  elbow  away  from  the  side  and  the  arm 
rotated  inward.  The  anterior  axillary  fold  is  lowered  upon  the 
injured  side.  The  long  axis  of  the  shaft  of  the  humerus  is  in- 
clined inward.  The  roundness  of  the  shoulder  is  flattened. 
The  acromial  process  is  prominent.  The  head  of  the  humerus 
is  out  of  the  glenoid  cavity,  and  most  often  lies  under  the  coracoid 
process.  The  elbow  can  not  be  brought  in  front  toward  the 
median  line,  nor  can  the  hand  of  the  injured  arm  be  placed  upon 
the  opposite  shoulder.     Active  and  passive  movements  at  the 


Fig.  170. — Dislocation  of  the  left  shoulder.  Note  the  flat  deltoid.  Prominence  under 
coracoid.  Direction  of  the  long  axis  of  the  humeral  shaft.  Lengthening  of  upper  arm.  Left 
nipple  lowered.     Anterior  axillary  fold  lowered. 


shoulder- joint  are  greatly  restricted.  Measuring  from  the  acro- 
mial process  to  the  external  epicondyle  of  the  humerus,  the 
upper  arm,  in  a  subcoracoid  dislocation,  is  lengthened.  A  soft 
crepitation  may  be  detected  in  manipulating  the  shoulder,  which 
simulates  bony  crepitus. 

Fracture    of    the   Anatomical    Neck    (see  Figures  171,   172, 
173,    174). — It   occurs    in    elderly  people.       It    is    often    over- 


i68 


FRACTURES    OF    THE    HUMERUS 


looked.  Swelling  of  the  shoulder  is  evident.  Anesthesia  is  often 
necessary  for  a  careful  examination  with  deep  palpation. 
There  is  thickening  of  the  neck  of  the  bone.  Crepitus  will  be 
felt  unless  the  fracture  is  impacted.  There  will  be  pain  upon 
moving  the  shoulder.  Abnormal  mobility  may  be  felt  high  up 
the  shaft  close  to  the  head  of  the  bone.  This  fracture  lies 
wholly  within  the  capsule  of  the  joint. 

I  am  inclined  to  think  that  this  fracture  impacted  is  far  more 
common  than  is  generally  supposed,  particularly  in  middle-aged 
and  elderly  people. 


Fig.  171.— Fracture  of  the  anatomical  neck  of  the  left  humerus.  Atropliy  of  the  shoulder 
muscles.  Deformity  at  the  seat  of  the  fracture,  seen  a  little  below  acromial  process  upon  the 
anterior  surface  of  the  shoulder  just  inside  the  white  line. 


It  is  most  often  unrecognized,  the  patient  being  told  that  he 
has  a  bruised  shoulder  and  that  pain  and  limitation  of  motion 
will  disappear  shortly. 

Such  patients  complain  of  persistent  pain  about  the  shoulder- 
joint,  limitation  of  motion  in  the  extremes  of  shoulder-joint  move- 
ments, rarely  joint  tenderness  to  pressure.  "The  shoulder  doesn't 
feel  right"  is  often  stated.  A  carefully  taken  X-ray  will  disclose 
a  fracture  of  the  anatomical  neck  of  the  humerus  with  some  little 
impaction  of  the  bone. 


SEPARATION    OF    THE    UPPER    EPIPHYSIS  169 

The  treatment  of  such  an  impacted  fracture  will  be  largely 
symptomatic.  Use  of  the  joint  early  and  within  the  limits  of  per- 
sistent after-pain  will  be  proper.  Moist  heat  to  the  shoulder  will 
relieve  the  pain  and  ache  in  such  a  shoulder  better  than  almost 
anything.  If  the  arm  feels  heavy  and  uncomfortable  it  may  be 
supported  by  a  properly  adjusted  sling.  This  fracture  has  its 
counterpart  in  old  people  in  the  impacted  fracture  of  the  neck  of 
the  femur.  Each  fracture  occurs  in  adult  life,  and  may  happen 
from  slight  trauma  and  is  rather  tedious  in  recovery. 


Fig.  172. — Normal  right  shoulder.     Compare  with  figure  170. 

Separation  of  the  Upper  Epiphysis  (see  Figs.  175,  176,  177,  178, 
179,  180). — The  separation  of  the  upper  humeral  epiphysis  will 
not  necessarily  open  the  joint  cavity,  for  the  capsular  ligament 
is  firmly  attached  to  the  epiphysis  and  the  synovial  membrane 
is  but  loosely  attached  to  the  diaphysis.  The  line  of  the  sep- 
aration of  the  upper  epiphysis  of  the  humerus  begins  on  the 
inner  side  of  the  head  of  the  bone  and  runs  across  almost  hori- 
zontally, rising  toward  the  center  of  the  shaft,  and  ends  in  the 


170  fracture;s  of  the  humerus 

outer  side  of  the  bone,  so  that  the  epiphysis  includes  the  tuber- 
osities. 

This  happens  to  young  people,  but  never  before  the  sixth 
year  and  never  after  the  twentieth  year.  The  most  frequent 
period  is  between  the  ages  of  nine  and  seventeen  years.  Or- 
dinarily, the  upper  end  of  the  lower  fragment  projects  forward 
and  inward,  producing  a  characteristic  deformity.     This  injury 


Fig.    173- — Fracture  of  the  anatomical  neck  of  the  left  humerus.    Sharp  deformity  ante- 
riorly characteristic.     Compare  with  figures  171  and  172. 

may  occur  either  with  or  without  displacement  of  the  shaft  of 
the  bone,  depending  upon  the  force  causing  the  injury  and  upon 
the  muscular  pull.  The  signs  are  a  little  like  those  attending 
a  fracture  of  the  surgical  neck  of  the  humerus.  There  may  be  no 
displacement  at  first  and  after  a  few  (three)  days  a  distinct  dis- 
placement appears,  especially  if  no  attempt  is  made  to  hold  the 
shoulder  still.  The  displacement  may  be  partial  or  complete. 
Partial  displacement  is  more  common  than  complete.     The  head 


SEPARATION    OF    THE    UPPER    EPIPHYSIS 


171 


of  the  bone  is  in  the  glenoid  fossa,  but  rotated  by  the  muscles 
attached  to  it  so  that  its  articular  surface  looks  downward.     It 


Fig.  174. — Fracture  of  the  anatomical  netk  of  the  hiiir.erus  (M.  G.  H.  series). 


Coracoid 

process.     Clavicle. 


—  Acromion. 

—  Epiphysis. 

--  Epiphyseal  line. 
/ \ Glenoid  fossa. 


Fig.   17s- — Normal  shoulder,  showing  epiphysis  of  upper  end  of  humerus  (X-ray  tracing). 

does  not  rotate  with  the  shaft.     The  crepitus  is  of  a  softer  quality 
than  in  cases  of  fracture — i.   e.,  cartilaginous.     Localized  pain 


172 


FRACTURES    OF   THE)    HUMERUS 


and  swelling  are  present.  A  puckering  of  the  skin,  caused  by 
the  hooking  of  the  lower  fragment  into  the  skin,  is  character- 
istic (see  Fig.  177).  Palpation  reveals  the  upper  end  of  the 
shaft  as  a  comparatively  smooth  surface,  unlike  the  end  of  a 
fractured  bone.  The  shoulder  maintains  its  rounder  natural 
appearance.  Grasping  the  head  of  the  humerus  angular  move- 
ment of  the  humeral  shaft  will  fail  to  move  the  head,  whereas 
rotatory  movement  may  move  it.  An  absence  of  shortening  of 
the  upper  arm  means  absence  of  great  displacement  and  untorn 
periosteum.     A  high  lesion  near  the  joint  in  a  young  patient. 


Fig.  176. — Separation  of  the  upper  epiphysis  of  the  humerus.  Incision  facilitated  accurate  reduc- 
tion. Reduction  maintained  by  abduction  and  sHght  rotation  outward  of  the  arm.  Arrow  points  to 
upper  end  of  shaft  of  humerus.  X  is  in  the  head  of  the  bone  articulating  with  the  glenoid  but  abnor- 
mally placed  as  compared  with  its  fellow  the  shaft. 

showing  displacement  forward  and  inward  of  the  shaft,  is  very 
suggestive  of  epiphyseal  separation. 

Treatment  of  Separation  of  the  Upper  Epiphysis  of  the 
Humerus. — When  there  is  no  displacement,  immobilization  of 
the  shoulder-joint  is  indicated. 

When  there  is  but  slight  displacement,  firm  pressure  with 
traction  will  ordinarily  correct  the  deformity. 


1 

1 

I 

1 

r 

'  ^ 

vj 

■L 

^* 

''       'm 

fcy 

M 

mUm 

Bl^i^ 

Fig.  177. — Separation  of  upper  epiphy- 
sis of  the  humerus  immediately  after  the 
accident.  Note,  especially,  position  of  up- 
per arm  and  position  of  head,  and  deep 
crease  in  skin  made  by  the  catching  of  the 
■skin  in  the  upper  end  of  the  lower  frag- 
ment.   Same  as  figure  178. 


Fig.  178. — Separation  of  the  upper  epiphy- 
sis of  the  humerus  (left).  Notice  shortening 
of  the  upper  arm.  Unusual  fullness  internal 
and  above  normal  position  for  head.  Same  as 
figure   179.    Line  points  to  deformity. 


Fig.  179- — Sepiirution  of  the  upper  epiphysis  of  the  left  humerus.  Notice  prominence  belo-.v 
•normal  place  for  humeral  head.  This  prominence  is  made  by  the  upper  end  of  lower  fragment.  Same 
case  as  figure   177.   White  line  marks  deformity. 


Clavicle.        Scapula. 


Fig.  i8o. — Fracture  of  high  surgical  neck,  or  separation  of  epiphysis  with  rotation  of  head 
(X-ray  tracing  of  figure  177). 


\ 


Epiphysis. 


. Lower  fragment 

and  callus. 


Fig.   iSi. — Old  fracture  of  surgical   neck   high  up,  simulating  true  epiphyseal   separation 

(X-ray  tracing). 


174 


Head  of  hu- 
merus. 


Shaft  of  hu- 
merus. 


Fig.  1S2. — High  fracture  of  surgical  neck,  simulating  separation  of  the  upper  epiphysis  of 
the  humerus..  Displacement  of  lower  fragment  inward.  Old  fracture  unreduced  (X-ray 
tracing).   • 


Fig.  183. — Fracture  of  the  surgical  neck  (X-ray  tracing),  showing  ordinary  displacement  of 
the  shaft  of  the  humerus. 


17s 


176 


FRACTURES    OF   THK    HUMERUS 


When  there  is  much  displacement,  reduction  is  often  not  only 
hard  to  effect,  but  sometimes  impossible  without  operative  as- 
sistance. 

The  chief  obstacle  to  reduction  is  the  position  assumed  by  the 
upper  fragment.  The  muscles  attached  to  the  tuberosity  draw 
the  upper  fragment  forward  and  outward  so  that  the  humeral 
articular  surface  looks  downward.  Albee  has  called  attention  to 
the  fact  that  placing  the  lower  fragment  in  line  with  the  displaced 
upper  fragment  that  is  abducting  the  upper  arm  will  permit  of 
reduction.  Fig.  193  shows  the  abducted  position  maintained  by  a 
plaster-of-Paris  plint. 


—  Head  of  humerus. 


1 Shaft  of  humerus. 


Fig.  1S4. — Fracture  of  the  surgical  neck  of  the  humerus.    Displacement  of  the  shaft  outward. 
Impossible  to  reduce  without  open  incision  (X-ray  tracing)  (Eliot). 

I  have  found  that  when  it  is  impossible  to  secure  reduction  by 
the  use  of  this  position,  an  incision  over  the  shoulder  longitudinally 
with  the  deltoid  fibers  and  separation  of  these  fibers  will  enable 
the  finger  to  be  introduced  to  the  seat  of  fracture,  then  intelligent 
traction  and  abduction,  together  with  slight  external  or  internal 
rotation  of  the  shaft,  will  reduce  the  fracture. 

It  is  important  to  put  the  arm  up  in  that  degree  of  abduction 
which  it  is  found,  with  the  wound  open,  will  best  maintain  re- 
duction. It  may  be  necessary  to  vary  the  angle  and,  at  times, 
to  put  the  arm  up  in  extreme  abduction  or  swung  forward. 


FRACTURE  OF  THE  SURGICAL  NECK 


177 


Other  obstacles  to  reduction  are  the  capsule  of  the  joint,  the 
bands  of  the  periosteum  or  fascia  or  the  muscles  or  tendon  of  the 
long  head  of  the  biceps  caught  between  the  fragments.  In 
operating  it  will  almost  never  be  necessary  to  resect  the  head  of 
the  bone.  In  almost  no  instance  can  it  be  determined  before 
operating  exactly  what  procedure  will  be  followed. 

Prognosis. — Usually  union  occurs,  if  there  is  no  displacement 
or  only  slight  displacement,  without  deformity  and  with  a  func- 


-—   Upper  fragment. 
--  Lower  fragment. 


A 

/    1 


Fig.  185. — Fracture  of  surgical  neck  of  the  humerus.  Same  as  figure  184  after  reduction 
by  open  incision  and  wiring  with  silver  wire.  Recovery  as  to  motion  complete  (X-rav  tracine-^ 
(Eliot).  y        '^         y  S) 


tionally  useful  shoulder.  If  there  is  great  displacement,  de- 
formity and  impairment  of  motion  will  persist  if  reduction  is  not 
complete.  The  growth  of  the  humerus  may  be  seriously  inter- 
fered with  if  an  unreduced  displacement  is  allowed  to  remain 
untreated. 

Fracture  of  the  Surgical  Neck  (see  Figs.  183,  184,  185).— 
Any  fracture  below  the  epiphyseal  line  of  the  upper  end  of  the 
humerus  and  well  within  the  upper  fourth  of  the  shaft  of  the  bone 
may,  for  all  practical  purposes,  be  regarded  as  a  fracture  of  the 
surgical  neck  of  the  humerus.     Fracture  of  the  surgical  neck  is 


178  FRACTURES    OF    THE    HUMERUS 

the  common  fracture  of  the  upper  end  of  the  humerus.  Fracture 
of  the  anatomical  neck  is  most  often  seen  in  the  aged.  Separation 
of  the  upper  humeral  epiphysis  occtus  in  youth. 

The  head  of  the  bone  is  found  in  the  glenoid  cavity.  Passive 
movements  are  associated  with  pain,  and  elicit  crepitus  and 
abnormal  mobility  at  the  seat  of  fracture,  provided,  of  course, 
the  fracture  is  not  impacted.  The  arm  is  slightly  shortened. 
The  arm  is  held  flexed,  with  the  elbow  at  the  side. 

If  after  an  injury  to  the  shoulder  no  positive  evidences  of 
fracture  or  dislocation  exist,  and  there  are  tenderness  and  localized 
swelling  about  the  joint,  and  motion  is  painful,  it  is  more  probable 
that  some  bony  lesion  exists  than  that  a  simple  contusion  is  present. 

Subperiosteal  Fracture  of  the  Upper  End  of  Humerus  in  Chil- 
dren.— J.  S.  Stone  has  called  especial  attention  to  a  group  of  sub- 
periosteal fractures  of  the  upper  end  of  the  humerus  occurring 
in  young  children  from  six  to  fourteen  years  of  age. 

The  injury  is  received  by  a  fall  upon  the  outstretched  hand  and 
is  followed  by  more  or  less  complete  inability  to  abduct  the  elbow 
from  the  side.  The  deltoid  seems  partly  paralyzed.  There  will 
be  detected  slight  muscle  spasm  about  the  shoulder  in  recent  cases 
and  tenderness  high  up  on  the  shaft  of  the  humerus.  There  will 
be  slight  pain  about  the  shoulder.  Crepitus  and  abnormal  mobil- 
ity will  be  absent.  An  X-ray  will  confirm  the  diagnosis  in  these 
somewhat  blind  cases.  Of  course,  the  line  cannot  be  sharply  drawn 
between  this  group  of  subperiosteal  fractures  and  those  instances 
of  fracture  in  the  same  region  attended  by  slight  displacement  or 
impaction  not  subperiosteal.  The  important  fact  to  be  kept  always 
in  mind  is  that  children  suffering  from  disability  of  the  shoulder 
of  an  indefinite  sort  as  determined  by  casual  examination  should 
be  examined  with  extreme  caution  in  order  to  detect  if  possible 
a  subperiosteal  fracture  of  the  upper  end  of  the  humerus.  The 
prognosis  and  treatment  will  be  far  more  definite  and  satisfactory 
if  the  exact  lesion  is  determined. 

Treatment. — Fracture  of  the  Anatomical  and  the  Surgical 
Neck  and  Separation  of  the  Upper  Humeral  Epiphysis. — The  im- 
portance of  these  lesions  demands,  as  has  been  said,  an  examina- 
tion with  the  aid  of  an  anesthetic.  It  is  even  much  more  im- 
portant, however,  that  the  first  retentive  dressing  be  applied  with 
the  assistance  of  an  anesthetic.     Traction,  countertraction,  and 


fracture;  of  the  surgicai.  neck  179 


Fig.  186.— Fissure  of  shaft  of  humerus  near  to  anatomical  neck  (adult)  and  running  down  into  shaft 

(Beck). 


Fig   187. — Fissure  of  high  shaft  of  humerus.     Compare  Fig.  i86  (Beck). 


FIk-  I'-io. — i'ratturc  of  the  surgical  neck  of  the  hujiiorus. 


Fig.    1S9. — ^Fracture  of  the  upper  end  of  the  humerus.     Note  hand,  forearm,  and  elbow  bao- 
daged  evenly  and  without  compression  ;  axillary  pad  and  strap. 


Fijg.   ipo- — Fracture  of  the  upper  end  or  shaft  of  the  humerus.     Posterior  view.     Note  bandage 
to  forearm  and  elbow  ;  axillary  pad  and  strap.     Note  shape  of  axillary  pad. 

180 


FRACTURES    OF   THR    UPPER   END    OF   THE    HUMERUS 


ISI 


manipulation  will  secure  coaptation  of  the  fragments.  To  hold 
these  fragments  securely  is  difficult.  To  hold  a  separation  of  the 
upper  epiphysis  in  position  may  be  impossible  without  operative 
assistance  (see  pages  172-176).  To  hold  any  one  of  these  frac- 
tures without  operative  interference  may  be  impossible. 

The  following  is  the  best  and  simplest  non-operative  method 
of  treatment  for  fracture  of  the  anatomical  and  surgical  neck: 
The  upper  arm,  shoulder,  and  trunk  should  be  thoroughly  pow- 
dered.     The   hand,    forearm,    and   elbow   should    be   bandaged 


Fig.  191- — Fracture  at  upper  end  of  the  humerus.     Note  hand,  forearm,  and  elbow  bandaged;  axil- 
lary pad  and  strap,  plaster-of-Paris  shoulder-cap,  sUng. 


evenly,  smoothly,  and  firmly  with  a  bandage  of  flannel — not 
cut  on  the  bias.  A  V-shaped  pad  (with  the  apex  of  the  V  in  the 
axilla)  constructed  of  sheet  wadding  with  cardboard  outside 
and  covered  with  cotton  cloth,  should  be  placed  in  the  axilla 
of  the  injured  side  (see  Fig.  189).  This  pad  is  firm,  and  fitted 
to  the  trunk  in  order  to  support  the  inner  side  of  the  upper  arm 
(see  Fig.  190).  If  thought  wise,  a  thin  coaptation  splint  may 
be  placed  between  this  pad  and  the  inner  side  of  the  upper  arm 
for  more  direct  support.  The  forearm  is  held  flexed.  The 
shoulder  is  now  well  padded  with  one  layer  of  sheet  wadding. 
A  plaster-of-Paris   shoulder-cap  is   applied   so   as   to  cover  the 


l82  FRACTURES    OF    THE    HUMERUS 

whole  shoulder,  the  anterior  and  posterior  aspects  of  the  chest, 
and  the  outer  side  of  the  upper  arm  down  to  the  external  condyle 
of  the  humerus  (see  Fig.  191).  This  shoulder-cap  is  made  of 
washed  crinoline,  six  layers  thick,  into  which  has  been  rubbed 
plaster-of-Paris  cream.  Its  exact  shape  and  extent  are  seen 
in  the  plates.  A  gauze  bandage  encircling  the  trunk,  arms,  and 
shoulders  should  be  used,  in  order  to  hold  the  upper  arm  at  the 
side  and  closely  applied  to  the  coaptation  splint  and  the  axillary 
pad,   and  in  order  to  secure  the  shoulder-pad  firmly  in  place. 


Fig.  192. —  Fracture  at  upper  end  of  humerus.  Arm  and  elbow  bandaged.  Axillary  pad 
and  shoulder-cap  in  position.  Application  of  circular  bandage  to  trunk  and  shoulder.  Sling 
not  shown. 


Often  better  than  the  plain  gauze  bandage  is  a  roller  bandage 
of  unwashed  crinoline,  which  is  applied  just  after  dipping  it  in 
lukewarm  water  (see  Fig.  192).  The  starch  of  the  crinoline 
bandage  after  being  wet,  stiffens  the  crinoline  as  it  dries  and 
makes  a  particularly  firm  and  efficient  dressing.  A  towel  folded 
thin  or  a  piece  of  compress  cloth  should  be  placed  against  the 
trunk  upon  the  well  side.  Against  this  the  circular  turns  of 
the  bandage  rest,  thus  causing  less  discomfort  to  the  patient  than 
if  they  bear  directly  upon  the  chest.     The  forearm  is  supported 


FRACTURES    OF    THE)    UPPER    END    OF    THE    HUMERUS        183 

by  a  cravat  sling  (see  Fig.  191).  By  this  method  of  immobiliza- 
tion no  active  traction  is  exerted  upon  the  lower  fragment. 
The  weight  of  the  arm,  being  unsupported  at  the  elbow,  exerts 
slight  traction. 

On  account  of  the  absence  of  active  traction,  ambulatory 
apparatus  can  not  hold  a  fracture  of  the  shoulder  properly  if 
there  is  much  displacement;  particularly  if  the  fracture  is  ob- 
lique. Ambulatory  apparatus  can  modify  muscular  action,  in- 
sure quiet  and  rest  to  the  part,  and,  except  in  the  instances  just 


Fig,  103. — Plaster-of -Paris  splint  applied  in  the  abducted  position  of  the  arm  to  maintain  the  reduction 
of  a  separation  of  the  upper  humeral  epiphysis  (Albee).     (See  p.  176.) 

noted,  approximately  maintain  the  position  secured  by  manipu- 
ulation  and  traction  and  countertraction.  On  account  of  its 
limitations,  therefore,  it  is  important  that  apparatus  should 
be  removed  at  regular  and  frequent  intervals  and  that  the  whole 
shoulder  should  be  examined  in  order  to  determine  errors  in 
position  and,  if  possible,  to  correct  them. 

After-care  of  a  Fracture  of  the  Shoulder. — Ordinarily,  the  great 
swelling  associated  with  this  injury  disappears  in  two  weeks. 
As  the  swelling  subsides,   the  normal  contour  of  the  shoulder 


1 84  FRACTURES    OF   THE    HUMERUS 

becomes  apparent  again.  It  is  necessary,  therefore,  to  alter 
the  shoulder  splint  and  to  apply  a  fresh  one.  When  the  patient 
wearing  a  shoulder-cap  lies  down,  there  is  a  tendency  for  the 
shoulder-cap  to  ride  up  and  away  from  the  shoulder.  This 
can  be  guarded  against  by  carrying  the  retaining  bandage  under 
the  firm  axillary  pad  and  well  over  the  shoulder.  Pressure 
points  should  be  carefully  watched,  and  the  pressure  removed. 
In  the  course  of  the  treatment  of  a  single  case  this  change  of  dress- 
ing will  have  to  be  made  two  or  three  times.  Union  will  be 
firm  in  from  three  to  four  weeks.  As  soon  as  union  is  firm,  all 
sphnts  may  be  omitted.  The  forearm  should  then  be  held  by 
a  sling  supporting  the  wrist.  At  night  it  will  be  wise  to  apply 
a  single  swathe  the  first  week  after  the  apparatus  is  left  off  in 
order  to  avoid  undue  motion  at  the  shoulder  during  sleep.  In 
these  injuries  about  the  shoulder-joint  passive  motion  should 
be  made  rather  early.  At  the  end  of  two  weeks  or  two  weeks 
and  a  half  repair  will  have  proceeded  far  enough  to  allow  of  the 
gentlest  movement  at  the  shoulder  without  causing  any  displace- 
ment of  fragments.  The  sooner  these  gentle  movements  can 
be  resumed  at  regular  and  short  intervals,  the  more  rapidly  the 
shoulder  will  improve.  The  common  occurrence  of  a  periarth- 
ritis after  an  injury  to  the  shoulder  emphasizes  the  necessity 
of  massage.  It  should  be  begun  as  early  as  the  second  or  third 
week. 

Prognosis  and  Result. — In  young  subjects  a  useful  arm 
will  result  (see  Fig.  194).  At  first,  if  there  is  great  difficulty 
in  maintaining  the  reduction  of  the  fragments,  the  surgeon 
will  expect  a  poor  result,  but  if  he  persists  in  efforts  at  retention 
and  uses  passive  motion  early,  gradually  the  movements  of  the 
arm  will  return  and  to  a  surprising  degree.  In  people  past 
middle  life  there  usually  is  a  little  shortening  of  the  upper  arm 
and  impairment  in  some  few  of  movements  of  the  shoulder,  as 
in  abduction  and  external  rotation.  In  individuals  over  fifty 
years  old,  excepting  those  with  rheumatism,  a  useful  but  not  a 
strong  shoulder  results  (see  Fig.  195). 

The  Prognosis  in  Separations  of  the  Epiphysis:  Bony  union 
is  to  be  expected.  If  there  is  little  or  no  displacement  of  frag- 
ments,   complete   restoration   of  function   will   result.     If  there 


FRACTURES   OF   THE    UPPER   END   OF   THE   HUMERUS  1 85 

is  some  deformity  remaining  after  consolidation  of  the  injury,  the 
usefulness  of   the  shoulder  is  ultimately  and   usually  restored. 


Fig.  194- — Young^  adult.     Fracture  of  the  surgical  neck  of  the  humerus  (X-ray  tracing,  fou* 
years  after  the  accident).     Abduction  and  rotation  very  slightly  limited.     Useful  arm. 


Fig.  I95- — Fracture.  Man  fifty-five  years  of  age.  High  surgical  neck  of  humerus.  At  the 
end  of  five  years  recovery  with  very  slight  limitation  of  motion  in  all  directions.  Abduction 
is  limited  nearly  one-half.  Useful  shoulder  (X-ray  tracing.  Massachusetts  General  Hospitalj 
1021). 

The  deformity  becomes  less  apparent  as  the  sharp  bony  corners 
are   smoothed  off  by  the  newly  forming  callus.     It  is  not  to  be 


1 86  FRACTURES    OF   THE    HUMERUS 

forgotten  in  considering  the  prognosis  after  all  shoulder  injuries 
that  much  of  the  persisting  disability  may  result  from  too  pro- 
longed immobilization  of  the  arm,  even  though  bony  displace- 
ment may  not  have  been  very  great.  The  growth  of  the  shaft 
of  the  humerus  in  length  proceeds  largely  from  the  upper  epiph- 
ysis. It  has  been  thought  by  many  that  an  arrest  of  growth 
of  the  humerus  will  follow  separation  of  this  upper  epiphysis. 
It  has  been  reported  to  have  occurred  in  eight  cases  but  in  no 
others.  In  several  of  these  cases  the  injury  to  the  shoulder 
was  thought  at  the  time  to  have  been  a  simple  contusion  or 
sprain.  A  loss  of  growth  is  not  likely  to  occur,  but  may  follow 
injury  to  the  upper  humeral  epiphysis. 

Oblique  Fracture  of  the  Surgical  Neck  with  Great  Displacement. — 
This  fracture  can  sometimes  be  held  by  placing  the  patient  in 
bed  upon  the  back  and  making  direct  traction  to  the  upper  arm 
and  countertraction  upon  the  shoulder  by  weight  and  pulley. 
If  the  fracture  can  not  be  easily  held  reduced,  it  will  be  wise  to 
make  the  closed  fracture  open  and  to  unite  the  two  fragments 
by  suture  (see  Figs.  184,  185). 

Fracture  with  Dislocation,  Fracture  of  the  Shoulder, 
Surgical  or  Anatomical  Neck  of  the  Humerus,  or  Separation 
of  the  Upper  Epiphysis  of  the  Humerus,  Together  with  a 
Dislocation  of  the  Upper  Fragment. — The  head  of  the  humerus 
is  found  in  an  unnatural  position  and  it  fails  to  move  when  the 
arm  is  rotated.  This  is  generally  thought  to  be  an  unusual  acci- 
dent, but  by  careful  examination  many  of  these  cases  may  be 
detected.  During  the  attempt  at  reduction  of  a  dislocated 
shoulder,  fracture  of  the  humeral  shaft  is  liable  to  occur.  Among 
many  cases  of  fracture  of  the  surgical  neck  the  fracture  occurred 
fifty-nine  times  while  an  attempt  at  reduction  of  a  dislocation  of 
the  shoulder  was  being  made. 

Treatment. — Obviously,  attempts  at  reduction  by  manipula- 
tion in  the  usual  way  will  meet  with  failure.  An  attempt  should 
always  be  made  to  reduce  the  dislocation  by  abduction  and  trac- 
tion upon  the  upper  arm  and  pressure  with  the  hand  upon  the 
loose  head  in  the  axilla.  It  may  be  possible  to  reduce  the  disloca- 
tion in  this  manner.  If  this  method  fails,  an  attempt  should  be 
made  to  reduce  the  dislocated  head  by  open  incision  (arthrotomy) 


I^RACTURES    OF   THE    UPPER    END    OF   THE    HUMERUS  1 87 

and  manipulation  of  the  upper  fragment  assisted  by  the  Mc- 
Bumey- Porter  hook  mano^uver.  If  this  attempt  is  successful, 
the  shaft  should  be  sutured,  with  an  absorbable  suture  or  fine 
silver  wire,  to  the  reduced  head,  and  the  shoulder  treated  as  if  a 
closed  fracture  existed. 

If  it  is  impossible  to  reduce  the  dislocated  head  or  if  the  head 
is  much  comminuted,  it  will  be  necessary  to  excise  it. 


Fig.  196. — X-ray  showing  fracture  of  the  greater  tuberosity  with  dislocation  of  the  head  of  the  humerus. 

If  operative  interference  has  been  decided  upon,  it  is  best  to 
defer  the  operation  until  the  acute  symptoms  have  subsided 
and  the  damaged  tissues  have  recovered  themselves.  It  is  the 
result  of  experience  that  operation  through  acutely  damaged 
tissues  is  unwise.  The  vitality  of  the  tissues  is  lessened  by 
trauma,  hence  the  resistance  to  infection  is  temporarily  impaired. 


1 88  FRACTURES    OF    THE    HUMERUS 

If  the  reduced  head  of  the  humerus  becomes  necrosed  and 
abscesses  form  about  the  joint,  an  unusual  occurrence,  the  head 
of  the  bone  should  be  immediately  excised  (see  Unreduced  Dis- 
location of  the  Humerus). 

The  After-treatment  of  Operated  Cases. — If  reduction  and 
suturing  have  been  accomplished,  passive  motion  should  not 
be  attempted  until  the  repair  at  the  seat  of  fracture  is  well 
under  wav.  This  will  be  about  the  second  week.  Then 
gentle  movement  may  be  made  and  gradually  increased. 

If  resection  has  been  performed,  passive  motion  should  be 
gently  begun  almost  immediately — i.  e.,  within  the  first  forty- 
eight  hours — and  persistently  continued.  The  muscles  of  the 
shoulder  should  be  massaged  and  treated  by  electricity.  Ab- 
duction should  not  be  attempted  to  any  great  extent  for  some 
weeks  after  the  operation  for  fear  of  displacing  the  upper  end 
of  the  humerus.  The  final  results  following  reduction  and  sutur- 
ing have  been,  as  a  rule,  excellent,  useful  arms  resulting  in  most 
cases.  The  results  following  excision  are  only  fairly  satisfactory. 
If  the  proper  amount  of  bone  has  been  removed,  ankylosis  will 
not  occur.  If  too  much  bone  has  been  removed,  a  dangling  or 
fiail  joint  will  result.     An  excision  is  to  be  avoided  if  possible. 

Indications  for  and  Results  of  Excision  of  the  Shoulder- 
joint  for  Fracture  and  Dislocation. — Excision  of  the  shoulder 
may  be  indicated  for  (i)  ankylosis  caused  by  tuberculosis,  by  an 
infectious  arthritis,  or  by  a  fracture;  (2)  for  a  crush  of  the  upper  end 
of  the  humerus,  i.  e.,  comminuted  fracture;  (3)  for  an  irreducible 
dislocation  of  the  humeral  head;  (4)  for  a  dislocation  of  the  humeral 
head  associated  with  a  fracture  of  the  anatomical  neck,  surgical 
neck,  or  greater  tuberosity. 

By  an  excision  of  the  shoulder  is  understood  ordinarily  not 
the  removal  of  the  articular  upper  end  of  the  humerus  and  the 
glenoid  surface  of  the  scapula,  but  the  removal  of  the  upper  end 
of  the  humerus  solely.  The  so-called  "excision,"  therefore,  is  a 
partial  excision,  not  a  complete  excision  of  the  shoulder-joint. 

The  amount  of  bone  removed  will,  of  course,  depend  upon 
the  exact  lesion  present.  The  smaller  the  amount  of  bone  re- 
moved the  better.  If  there  is  an  anatomical  neck  fracture  with 
a  dislocation,  usually  it  is  wise  to  remove  the  anatomical  head  of 


FRACTURES    OF   THE    UPPER   END   OF   THE    HUMERUS  1 89 

the  bone.  If  there  is  a  surgical  neck  fracture  every  effort  should 
be  made  to  reduce  the  displaced  head,  and  then  to  secure  apposi- 
tion of  the  fractured  bones.  The  removal  of  the  head  and  shaft 
above  a  surgical  neck  fracture  may  be  at  times  absolutely  neces- 
sary, but  it  results  in  great  impairment  of  motion  at  the  shoulder- 
joint. 

I  have  studied  the  results  of  excision  of  the  shoulder  in  nineteen 
cases.  All  were  subcoracoid  dislocations  of  the  shoulder  excepting 
two ;  one  of  these  was  a  posterior  dislocation  and  one  was  a  sub- 
glenoid dislocation.  These  cases,  coming  from  one  cUnic,  that  of 
the  Massachusetts  General  Hospital,  have  been  treated  under 
very  similar  conditions.  They  are  comparable  cases.  They  form 
a  group  of  very  considerable  practical  importance. 

The  mortality  in  these  nineteen  cases  is  zero.  The  results 
obtained  in  this  group,  together  with  those  found  in  the  care- 
fully analyzed  series  of  cases  in  literature,  consisting  of  twenty- 
one  excisions  (Mason), ^  establishes  a  standard  for  excisions  of  this 
joint  in  forty  comparatively  recent  cases. 

Following  the  excision  of  the  upper  end  of  the  humerus  there 
will  be  limited  power  in  the  shoulder;  a  distinct  diminution  in 
strength;  limited  active  motion  in  abduction,  in  adduction,  and 
in  anterior  and  posterior  swing;  muscular  atrophy;  possibly  the 
loiiriation  of  plaques  of  new  bone  about  the  old  joint  from  de- 
tached periosteum.  These  pieces  of  new  bone  may  seriously  im- 
pair motion.  Deformity  and  pain  may  follow  an  excision  of  the 
shoulder-joint. 

These  nineteen  operations  were  done  either  immediately  after 
the  receipt  of  the  injury  or  from  one  to  eight  months  following  the 
injury.  Twelve  of  these  excisions  of  the  shoulder  were  for  frac- 
ture or  dislocation,  the  remainder  were  for  tuberculosis.  Almost 
always  the  anterior  incision  was  employed.  Many  of  the  results 
were  functionally  useful.  The  surgeon's  standard  of  result  is  high. 
The  patient's  standard  of  result  is  relatively  low.  The  surgeon 
is  looking  for  restoration  to  the  normal,  an  absolute  result.  The 
patient  is  looking  for  an  amelioration  of  the  disability  occasioned 
by  the  original  accident — any  improvement  is,  therefore,  hailed 
by  him  with  delight. 

'  Annals  of  Surgery,  May,  1908. 


I90  FRACTURES    OF    THE    HUMERUS 

It  is  very  generally  accepted  that  the  reposition  of  the  head  of 
the  dislocated  humerus  is  the  ideal  treatment  for  cases  of  fracture 
dislocation  or  of  unreduced  dislocations,  because  the  reports  from 
such  reposition  give  better  functional  results  than  treatment  by 
any  other  method. 

The  result  following  an  operative  reposition  or  reduction  is 
better  always  than  the  result  of  an  excision.  For  this  reason 
.Curtis  has  very  properly  designated  (and  Mason  has  lately  followed 
Curtis)  the  results  of  reposition  as  perfect,  good,  and  fair;  while 
the  results  of  excision  of  the  shoulder  are  classified  as  good,  fair, 
improved,  and  bad.  The  best  excision  can  only  be  a  good  result. 
It  is  never  equal  to  the  perfect  reposition.  The  fair  or  second-best 
excision  will  be  no  better  than  a  good  reposition.  This  classifica- 
tion of  results  has  been  used  in  applying  the  cases  here  recorded. 

In  certain  cases  an  arthroplasty  of  some  form  ma}^  improve  the 
results  of  simple  reposition  even  beyond  what  they  are  at  present. 
The  better  functional  result  of  operative  reposition  over  excision 
should  induce  the  surgeon  to  make  every  effort  at  reposition  before 
excising  the  head  of  the  bone. 

I  am  quite  positive  that  excision  is  too  often  done  because  it  is 
a  little  easier  and  quicker  than  attempts  at  operative  reduction. 
If  one  wishes  to  secure  ultimately  the  best  for  his  patient  he 
will  make  safe  but  strenuous  efforts  to  reduce  the  head  of  the 
bone  and  not  to  excise  it.  The  too-frequently  poor  result  follow- 
ing excision  emphasizes  the  importance  of  this  suggestion  as  to 
treatment. 

An  individual  unable  to  put  hand  to  head,  unable  readily  to 
feed  himself,  because  of  limited  power  in  forward  swing  and  ab- 
duction— incapacitated  for  the  ordinary  acts  of  life,  to  say  nothing 
of  loss  in  trade  or  business — is  seriously  handicapped.  Function- 
ally, the  result  of  a  dislocated  shoulder  replaced  by  manipulation 
may  be  serious,  of  a  fracture  dislocation  of  the  shoulder  replaced 
by  incision  may  be  much  more  serious,  of  a  fracture  dislocation 
excised  may  be  most  serious. 

About  59  per  cent,  of  these  cases  had  fair  results.  I  am  im- 
pressed by  the  disability  following  excision  of  the  shoulder. 

The  farther  away  from  the  joint  the  fracture  occurs — i.  e.,  the 
nearer  the  fracture  is  to  the  shaft — the  greater  is  the  likelihood  of 


FRACTURES    OF   THE)    UPPER   END    OF   THE    HUMERUS  19I 

being  able  to  reduce  the  displaced  head  by  hook,  by  digital  pressure, 
by  periosteum  elevator,  or  by  blunt  dissector  leverage.  Every 
reasonable  effort  should  be  made  to  secure  an  ideal  result.  Repo- 
sition is  ideal.     Excision  at  best  is  but  second  best. 

Case  of  Fracture  Dislocation  of  the  Right  Shoulder.     Excision  of 
Humeral  Head.— Report  eight  years  after  operation  (Fig.  197). 


Fig.  197.— Fracture  dislocation  of  the  right  shoulder.     Excision.     Condition  eight  years  subsequently. 

(M.  G.  H.  series). 

vS.  F.  H.,  No.  104073.  Dentist.  A  man  sixty-four  years  old. 
Eight  weeks  before  he  had  received,  through  a  fall,  a  fracture  of 
the  humerus  and  a  dislocation  of  the  head  of  the  bone.  Excision 
of  the  head  of  the  humerus  was  done.     The  wound  was  drained. 

Eight  years  subsequently  the  following  report  is  received.  He 
is  able  to  do  a  great  deal  of  work  with  the  arm.     He  can  put  the 


192 


FRACTURES    OF    THE    HUMERUS 


index-finger  to  the  lobe  of  the  ear.  He  cannot  feed  himself  with 
that  hand.  He  has  little  trouble  excepting  some  rheumatism  at 
times  (see  Fig.  197). 

Case  of  Fracture  Dislocation  of  the  Left  Shoulder.     Excision  of 
the  Head  of  the  Humerus.— Result  nine  years  later  (Fig.  198). 


Fig.  19S. — Fracture  dislocation  of  the  left  shoulder.  Excision  of  the  head  of  the  humerus.  Result 
nine  years  later.  Note  the  atrophy  of  the  deltoid  on  the  left  side.  Note  the  deformity  of  the  shoulder 
region  (M.  G.  H.  series). 


A.  F.  P.,  No.  105896.  A  man  forty-eight  years  old,  a  sailor. 
Following  a  violent  blow  upon  the  left  shoulder  two  months  ago  a 
fracture  of  the  anatomical  neck  together  with  a  dislocation  re- 
sulted. All  motions  of  the  shoulder  were  much  limited  and 
painful. 

An  excision  of  the  head  of  the  bone  was  done  with  difficulty. 
The  chisel  was  needed  to  free  the  bone  completely.  Many  peri- 
articular adhesions  were  divided. 


FRACTURES    OF    THE    UPPER    END    OF    THE    HUMERUS         1 93 

Nine  years  later  he  reports  that  he  is  able  to  work  every  day. 
The  arm  bothers  him  very  little.  He  cannot  put  his  right  hand 
upon  his  head,  but  he  can  put  on  and  take  off  his  hat  with  his 
right  hand.     He  says  his  arm  is  as  good  as  he  can  expect. 

Ten  years  later  he  can  place  hand  on  neck,  but  not  on  shoulder. 
He  can  move  arm  in  abduction  45  degrees.  He  can  put  hand 
behind  back  (see  Fig.  198). 

Case  of  Fracture  of  the  Anatomical  Neck  of  the  Right  Humerus  with 
Dislocation  of  the  Shoulder.  Excision  of  the  Head  of  the  Humerus. — 
Report  after  nine  months. 


Fig.  199. — Fracture  of  the  anatomical  neck  of  the  humerus.     Excision  of  the  head  of  the  bone.     Result 
nine  months  later  (see  Fig.  200). 


G.  A.  Man.  Clerk,  thirty-one  years  old.  Fell  and  sustained  a 
subcoracoid  dislocation  of  the  right  humerus  six  weeks  previously. 
Because  of  a  fracture  of  the  anatomical  neck  of  the  humerus  it 
was  impossible  to  reduce  the  dislocation.  Consequently,  an  ex- 
cision of  the  head  of  the  bone  was  performed  through  the  anterior 
incision. 

Nine  months  later  he  has  fair  use  of  the  arm.     All  attempts 
at  abduction  are  associated  with  movements  of  the  scapula  (see 
Figs.  199  and  200). 
13 


194 


FRACTURES   OF   THE   HUMERUS 


Fig.  200.— Anatomical  neck  fractured  in  Fig.  19S.    This  is  the  head  of  the  bone  removed  (see  Fig.  199). 


Case  of  Dislocation  Fracture  of  the  Left  Shoulder.  Irreducible, 
No  Operation  Done. — Result  six  years  after  the  accident  (Fig. 
202). 

The  patient  is  able  to  put  the  left  hand  upon  the  top  of  his 
head  without  bending  the  head  more  than  a  trifle.  He  cannot 
quite  place  the  left  hand  squarely  upon  the  right  shoulder.     He 


Fig.  201. — Irreducible  fracture  dislocation  of  the  left  shoulder,  imoperated  upon.     Condition  six  years 
after  operation  (see  X-ray  plate,  Fig.  202). 


can  place  the  left  hand  behind  his  back,  but  a  little  less  readily 
than  the  right  hand. 

He  can  raise  his  left  arm  to  a  horizontal  in  the  forward  swing. 
He  can  abduct  the  left  arm  slightly  beyond  a  right  angle. 

There  is  a  little  difference  in  his  reach,  the  left  arm  being  slightly 


FRACTURES    OF   THE)    UPPER   END   OF   THE    HUMERUS 


195 


shorter  than  the  right.  The  left  arm  hangs  away  from  the  side 
further  than  the  right.  The  back  of  the  left  hand  faces  forward. 
He  has  some  discomfort  at  times  because  of  a  little  "catching," 
as  he  expresses  it,  in  the  left  shoulder.  The  left  arm  gets  a  little 
more  tired  at  times  (see  Figs.  201  and  202). 


Fig.  202. — X-ray  of  Fig.  291,  showing  fracture  dislocation  of  the  humeral  head.    Note  greater  tuber- 
osity fractured.     Note  loss  of  contour  of  end  of  the  bone.     Six  years  since  accident. 


This  case  of  unreduced  and  unoperated  fracture  dislocation  of 
the  shoulder  is  most  instructive.  The  patient  was  an  adult, 
a  superintendent  in  a  brewery.  Six  years  ago  he  fell,  dislocating 
the  left  shoulder,  fracturing  at  the  time  the  greater  tuberosity  of 
the  humerus  (see  X-ray,  h'ig.  202).    To-day,  six  years  after  the  in- 


196  FRACTURES    OF  THE    HUMERUS 

jury,  he  has  recovered,  with  a  remarkably  useful  shoulder,  although 
the  humeral  head  is  still  dislocated.  The  extent  (see  Fig.  201)  of 
the  movements  at  the  shoulder-joint  is  best  seen  in  the  photo- 
graphs. He  complains  only  that  the  arm  becomes  a  little  tired 
after  some  hours'  walking  about.  It  seems  to  him  less  well-sup- 
ported at  the  shoulder  than  the  other  arm.  Resting  the  hand  in 
the  coat  for  a  few  moments  relieves  him  of  this  tired  feeling. 

Other  similar  cases  have  been  recorded.  The  results  in  certain 
of  unoperated  and  unreduced  dislocations  are  as  good  as  in  some 
excisions  of  the  shoulder,  and  are  often  better  than  in  many  ex- 
cisions of  the  shoulder. 

If  reposition  by  manipulation  or  incision  is  impossible,  and 
there  is  no  pain  for  which  excision  is  demanded,  it  may  be  wise 
in  a  certain  very  limited  class  of  cases  to  avoid  an  excision  of 
the  head  of  the  bone.  Certain  it  is  that  in  a  few  irreducible  and 
unreduced  cases  of  dislocation  of  the  upper  end  of  the  humerus 
a  remarkably  good  result  has  followed  without  excision. 

FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS 
Fracture  of  the  shaft  of  the  humerus  may  occur  at  any  point 
between  the  surgical  neck  and  the  condyles.  Its  common  seat 
is  at  the  middle  or  in  the  lower  third  of  the  bone  (see  Fig.  204). 
The  twisting  force  exercised  in  the  breaking  up  of  adhesions  in 
and  about  the  shoulder-joint  will  often  fracture  a  humeral  shaft 
obliquely.  The  strength  test  of  the  arms,  as  seen  in  the  illus- 
tration, has  been  the  cause  of  spiral  fracture  of  the  humerus 
(see  Figs,  205,  206). 

Symptoms. — The  symptoms  are  readily  recognized.  They 
are  swelling  at  the  seat  of  fracture,  pain,  crepitus,  abnormal 
motion,  and  ecchymoses.  Paralysis  of  the  musculospiral  nerve 
may  occur,  with  the  characteristic  wrist-drop.  Ordinarily,  the 
attention  of  both  the  patient  and  the  surgeon  is  so  occupied 
with  the  fracture  of  the  bone  and  its  associated  loss  of  movement 
that  loss  of  power  and  sensation,  because  of  involvement  of  the 
nerve,  goes  unrecognized.  If  injury  to  the  musculospiral  nerve 
is  not  recognized  at  the  outset,  it  may  be  overlooked  until  the 
splints  are  removed.  The  exact  duration  and  the  cause  of  the 
paralysis  can  not  then  be  readily  ascertained.     The  patient  may 


Shaft  of  humerus,  upper 
fragment. 


Shaft  of  humerus,  lower 
fragment. 

Fig.  203. — Fracture  of  shaft  of  humerus,  high.    Displacement  of  lower  end  of  upper  frag- 
ment inward  (X-ray  tracing). 


Sha- 1  of  humerus. 


Shaft  of  humerus,  upper 
fragment. 


Ulna. 


FiK.  204.— Fracture  of  the  shaft  of  the  humerus  in  lower  third.     Displacement  of  both  frag- 
ments forward  (X-ray  tracing). 


tq7 


198  Fractures  op  thk  humerus 

wrongly  attribute  the  paralysis  to  the  pressure  of  the  splints. 
Very  rarely,  injury  or  pressure  upon  the  large  vessels  of  the  arm 


Fig.   205. — Trial  of  strength  of  arms  resulting  sometimes  in  spiral  fracture  of  the  humerus 

(Monks).     See  figure  206. 


V 


Fig.  206. — Illustrating  spiral  fracture  of  humerus  (Monks).     See  figure  205. 

is  met  with.     Damage  to  the  artery  will  be  suggested  by  weak 
or  absent  pulse  at  the  wrist  or  by  local  evidences  of  hemorrhage. 


TREATMENT    OF   FRACTURES   OF   TftlE    SHAFT 


199 


A  swelling  appearing  suddenly,  greater  than  that  which  would 
appear  from  the  laceration  of  soft  tissues  alone,  should  suggest 
rupture  of  large  vessels.  Measurement  of  the  humerus  should 
be  made  from  the  edge  of  the  acromial  process  to  the  external 


Fig.   207. — Longitudinal  fracture  of  shaft  of  humerus  into  the  joint.     Displacement  of  smaller 
fragment  backward.     Note  space  between  fragment  and  shaft.     Arm  extended. 


condyle  of  the  humerus   (see  Fig.   168).     The  amount  of  over- 
lapping of  the  fragments  will  be  shown  by  this  measurement. 

Treatment. — For  purposes  of  treatment,  fractures  of  the  shaft 
may  be  grouped  into  those  with  little  or  no  displacement  and 


200 


FRACTURES    OF   THE    HUMERUS 


those  with  considerable  displacement  and  difificult  of  retention 
after  reduction.  The  fracture  should  be  reduced  by  traction 
upon  the  condyles  of  the  humerus  and  countertraction  upon 
the  upper  arm  and  by  manipulation  of  the  fractured  bones. 
Treatment  of  Fractures  of  the  Shaft  of  the  Humerus  with  Little 


Fig.  208. — Same  as  figure  207.   Note  the  disappearance  of  space  between  fragments  with  cor- 
rection of  deformity  upon  flexing  forearm.     Position  reduces  the  fracture. 


or  no  Displacement  (see  F'igs.  209,  210). — The  following  materials 
are  needed  for  the  apparatus  to  be  used:  Ordinary  dusting- 
powder, — which  is  powdered  oxid  of  zinc  and  powdered  starch, 
equal  parts;  a  bandage  of  Shaker  flannel  three  inches  wide,  not 
cut  on  the  bias ;  an  axillary  pad  made  with  several  layers  of  sheet 


Fig.   209. — Fracture  of  the  shaft  of  the  humerus.     Note  bandage  to  hand,  forearm,  and  elboWj 
axillary  pad  and  strap;  coaptation  splints  and  sling.     Bandage  does  not  cover  fracture. 


F\k-  210. — Fracture  of  the  shaft  of  the  humerus.  Note  bandage  to  hand,  forearm,  and 
elbow;  adhesive-plaster  swathe  holding  arm  upon  axillary  pad  and  covering  coaptation 
splints,    bling;. 

201 


202 


Fractures  of  the  humerus 


wadding  covered  with  a  folded  piece  of  pasteboard,  and  the  whole 
inclosed  in  cotton  cloth  stitched  at  the  edges ;  the  pad  is  V-shaped, 
and  long  enough  to  extend  from  the  apex  of  the  axilla  to  just 
above  the  internal  condyle  of  the  humerus ;  it  is  broad  enough  to 
support  the  upper  arm  comfortably  and  securely;  the  lower 
part  of  the  pad  is  about  three  inches  thick  (see  Fig.  211),  so  as 
to  support  the  arm  only  a  trifle  abducted  from  the  side — that 
is,  just  away  from  the  perpendicular.  If  the  axillary  pad  is 
too  short,  there  is  danger  of  causing  an  outward  bowing  of  the 


_  Space 
'  between 

side  and 

arm. 


Fig.  211.— Note  the  space  to  be  filled  by  suitable 
pad  between  the  inner  side  of  upper  arm  just  above 
elbow  and  the  chest  and  loin  in  case  of  fracture  to 
shaft  of  humerus. 


Fig.  212.  213. — Coaptation  splint 
seen  flat  and  in  section.  Made  by  lay- 
ing thin  wood  on  adhesive  plaster  and 
splitting  the  wood  with  knife. 


humerus  (see  Fig.  222).  Two  straps  are  attached  to  the  upper 
corners  of  the  apex  of  the  V-shaped  pad  long  enough  to  surround 
the  body  and  go  over  the  opposite  shoulder.  These  straps  hold  the 
pad  in  position.  The  remaining  apparatus  consists  of  two  or  three 
thin  coaptation  splints  for  application  to  the  upper  arm ;  these  are 
made  readily  by  laying  thin  splint  wood  upon  adhesive  plaster, 
and  splitting  the  wood  longitudinally  (see  Fig.  212);  three  adhesive 
straps  two  inches  wide  to  hold  the  coaptation  splints;  an  ad- 
hesive plaster  swathe  wide  enough  to  extend  from  the  acromion 
tip  to  the  external  condyle,   and  long  enough  to  surround  the 


Fig.  2 14. — Humerus  splint  in  position,     (v.  Hacker's  clinic.) 


Fig.  215.— Splint  for  fr.K  lure  of  (Ik-  liumrrus:   A ,  Cfiest  picrc;  B,  upper  arm  support;  C,  forearm  splint; 
E,  reinforced  angle  (Osgoorl  and  Penhallow). 


203 


Fig.  216. — Humerus  splint  in  pdsiliiui  and  lickl  by  bandages  about  neck,  trunk,  upper  and  forearm, 
and  liand.     (v.  Hacker's  clinic.) 


Fig.  217. — Splint  for  fracture  of  the  shaft  of  the  humerus:  Pads  applied  before  adhesive  swathe  is  in 
place  (Osgood  and  Penhallow). 


204 


Fig.  218. — Splint  for  fracture  of  the  shaft  of  the  humerus.     Posterior  view  (Osgood  and  Penhallow). 


Fig.  219.— A  splint  for  holding  comfortably  and  advantageously  a  fracture  of  the  shaft  of  the  humerus. 
Splint  made  of  heavy  cardboard  reinforced  by  adhesive  jjlaster  strips,      (v.  Haclcer's  clinic.) 


s 


D 


Fig.  220. — The  strip  of  heavy  cardboard  or  mill  board,  showing  in  diagram  proportional  length  of  the 
three  parts  and  the  oblique  bending  of  the  strip,     (v.  Hacker's  clinic.) 

205 


2o6 


FRACTURES    OF    THE    HUMERUS 


body  and  upper  arm;  a  cravat  sling;  a  thin  towel  or  piece  of 
compress  cloth  for  the  forearm  to  rest  upon.  All  these  articles 
should  be  in  readiness. 

Etherization  of  the  patient  will  rarely  be  necessary.  In  cases 
of  nervous  and  sensitive  women  and  unmanageable  young  chil- 
dren it  will  be  wise  to  use  an  anesthetic.  The  whole  upper 
extremity,  axilla,  and  chest  should  be  washed  with  soap  and 
water,  thoroughly  dried,  and  dusted  with  powder;  then  the 
reduced  fracture  is  held  in  position  by  an  assistant  while  the 


Fig.  221 — Ambulatory  traction.  Fracture  of  the  shaft  of  the  humerus  at  X.  Overriding 
and  lateral  displacement  of  fragments.  Note  :  Coaptation  splints,  internal  right-angle  splints. 
Two  weights,  one  pulling  through  medium  of  right-angle  splint  and  the  other  through  adhe- 
sive plaster  attached  to  upper  arm  as  high  as  the  seat  of  the  fracture.  Note  :  Sling  as  a  cravat 
supporting  only  the  wrist.     Traction  is  thus  exerted  upon  the  lower  fragment  of  the  humerus. 


apparatus  is  being  applied.  The  hand,  forearm,  and  elbow 
should  be  loosely  but  evenly  covered  by  a  flannel  bandage  (see 
Fig.  189).  The  upper  arm  should  be  surrounded  by  the  coap- 
tation splints,  held  in  place  by  the  three  straps  of  adhesive 
plaster,  so  as  to  secure  the  fractured  bone  perfectly  (see  Fig. 
209).  The  auxiliary  pad  should  be  placed  in  the  axilla  and  held 
by  the  straps  passed  over  the  opposite  shoulder  and  under  the 


TREATMENT  OF  FRACTURES  OF  THE  SHAFT 


207 


opposite  axilla.  The  upper  arm  should  rest  comfortably  upon 
the  pad.  To  prevent  chafing,  the  thin  towel  or  compress  cloth 
should  be  placed  beneath  the  forearm  where  it  touches  the  body: 
The  plaster  swathe  should  then  be  applied  over  the  arm  to  the 
body,  so  as  to  encircle  completely  the  trunk  (see  Fig.  210).  Thus 
the  arm  is  absolutely  fixed  to  the  axillary  pad  and  side.  The 
"wrist  should  be  supported  in  a  cravat  sling  passed  around  the 
neck.  The  elbow  is  left  unsupported.  The  weight  of  the  upper 
extremity   will   thus    tend    to    exert    slight   downward    traction 


Fig.  222. — Showing  effect  (bowing  outward)  of  too  short  an  axillary  pad  upon  a  fracture  of 
the  shaft  of  the  humerus. 


upon  the  lower  fragment  of  the  humerus.  Under  no  circum- 
stances should  an  ordinary  broad  sling  be  used,  because  of  the 
danger  of  making  upward  pressure  upon  the  forearm  and  elbow 
and  so  pushing  up  the  lower  fragment  of  the  humerus.  The 
elbow-joint  should  not  be  immobilized  for  the  reason  that  it 
would  then  be  much  more  difficult  to  hold  the  seat  of  fracture 
fixed.  With  the  elbow-joint  fixed,  the  lower  arm  of  the  lever 
is  greatly  increased,  and  instead  of  movement  of  the  forearm 
taking  place  at  the  elbow-joint  it  would  take  place  at  the  seat 
of  fracture.  Fractures  of  the  shaft  of  the  humerus  are  frequently 
treated  by  an  internal  angular  splint  and  coaptation  splints,  the 
upper  ends  of  the  splints  barely  reaching  the  fracture,   or,   at 


2o8 


FRACTURES    OF   THE    HUMERUS 


best,  being  an  inch  or  two  above  it  (see  Fig.  223).  When  the 
fracture  of  the  bone  is  within  the  lower  third  of  the  shaft,  then 
and  then  only  should  an  internal  angular  splint  be  used  in  con- 
nection with  coaptation  splints.  The  Osgood  and  Penhallow 
splint  of  tin  is  sometimes  of  great  service  (see  Figs.  215,  etc.). 
The  sphnt  of  card-board  from  the  clinic  of  v.  Hacker  is  often 
indicated  (see  Figs.  219,  etc.). 

After-treatment. — The  patient  should  be  seen  each  day  for 
the  first  three  days  in  order  that  the  surgeon  may  be  informed 
as  to  the  exact  condition  of  the  parts.     There  may  be  undue 


Fig.   223. — High  fracture  of  the  shaft  of  the  humerus.     A  common  and  improper  use  of  an 
internal  right-angle  splint. 


pressure.  The  patient  may  be  uncomfortable.  The  splints 
may  need  readjusting.  Attention  to  little  details  of  discom- 
fort is  important.  The  dressing  should  be  reapplied  with  great 
care  once  each  week.  The  parts  covered  by  splints  should  at 
each  dressing  be  carefully  inspected  to  detect  any  points  of  undue 
pressure,  indicated  by  reddening  of  the  skin.  If  these  are  dis- 
covered, they  should  be  washed  with  alcohol  and  covered  with 
flexible  collodion  or  a  drying  powder.  The  undue  pressure  should 
be  removed  by  shifting  the  padding.     Union  will  be  found  to 


tre;atment  of  fractures  of  the  shaft 


209 


be  firm  after  about  three  or  four  weeks.  As  soon  as  union  is 
solid, — at  the  end  of  four  or  five  weeks, — the  swathe  may  be 
omitted,  the  coaptation  splints  alone  being  a  sufficient  support. 
After  about  five  weeks  or  five  weeks  and  a  half  all  support  may 
be  removed  from  the  arm.  The  arm  is  then  put  in  the  sleeve 
of  the  clothes,  and  the  wrist  supported  by  a  sling.  After  eight 
weeks  the  sling  may  be  discarded  and  moderate  and  careful  use 
of  the  limb  in  light  movements  be  indulged  in. 

Fracture  of  the  Shaft  of  the  Humerus  with  Considerable  Dis- 
placement.— Obviously,    the    method    described    for    the    treat- 


Fig.  224. — Fracture  of  the  shaft 
of  the  humerus.  Note  the  loose 
fragment.  Note  the  comparative 
ease  of  complete  reduction  and  re- 
tention if  fragments  are  held  by  en- 
circling suture. 


Fig.  225. — Fracture  of  the  lower  part  of 
the  shaft  of  the  humerus.  Note  displace- 
ment of  upper  fragment  backward. 


ment  of  fractures  without  great  displacement  will  be  of  com- 
paratively little  value.  Occasionally,  it  will  be  found  that  this 
method  will  hold  even  greatly  displaced  fractures;  it  should 
then  be  used.  The  ideally  perfect  method  for  such  cases  is 
traction  and  countertraction  upon  the  arm  with  the  patient 
lying  on  the  back  in  bed.  Coaptation  splints  should  be  used, 
as  in  simple  uncomplicated  fractures.  If  all  methods  fail  to 
hold  the  fragments  reduced,  open  incision,  reduction  of  the 
displacement,  and  suturing  of  the  fragments  are  indicated. 
The  plaster-of- Paris  splint,  applied  with  the  plaster  roller  to 


14 


2IO 


FRACTURES    OF    THE    HUMERUS 


the  forearm  and  arm,  and  the  spica  bandage  to  the  shoulder 
and  chest  are  often  efficient  in  these  difficult  cases.  In  the 
application  of  this  splint  it  is  of  supreme  importance  that  an 
assistant  hold  the  arm  so  that  the  alinement  of  the  bones  re- 


Fig.  226.— Fracture  of  the  shaft  of  the  humerus  through  condyles.     Note  displacement  of 
upper  fragment  backward. 


Fig.   227. — Injury  to  the  upper  end  of  the  ulna  and  the  lower  end  of  the  humerus. 


mains  perfect.  The  assistant  who  holds  the  arm  should  have 
nothing  else  to  do.  Before  applying  the  plaster-of-Paris  splint 
it  is  often  advisable  to  apply  thin  coaptation  splints  at  the  seat 
of  fracture  to  give  additional  strength  to  the  sphnt.     With  these 


TREATMENT  OF  FRACTURES  OF  THE  SHAFT 


211 


coaptation  splints  in  use  a  lighter  plaster  splint  may  be  applied 
without  sacrificing  strength.  A  narrow  cotton  swathe  about 
the  body  and  arm  should  steady  the  upper  extremity.  The 
wrist  should  be  supported  by  a  cravat  sling. 

The  after-care  of  a  case  treated  by  the  plaster  splint  will  be 
similar  to  that  following  any  other  treatment  after  union  has 
occurred.     The  plaster  may  be  left  in  situ  for  four  weeks;  then, 


Fig.  228.— Case:  Fracture  of  the  shaft  of  the  left  humerus.     Fracture  united.     Note  atrophy 
of  upper  arm,  including  deltoid.     Loss  of  muscular  contour  very  apparent. 

ordinarily,  repair  will  be  found  so  far  advanced  that  the  plaster 
splint  may  be  dispensed  with  and  the  ordinary  coaptation  splints 
and  swathe  may  be  used.  If  the  plaster  splint  has  proved  com- 
fortable, it  may  be  split  and  reapplied. 

Massage  and  Passive  Motion :  In  view  of  the  possibility  of  non- 
union of  this  fracture,  it  will  be  wise  not  to  begin  massage  until 
union  has  begun.  Passive  motion  to  the  shoulder  and  elbow 
should  be  gently  made  at  as  early  a  date  as  possible,  with  due 


212  FRACTURES    OF   THE    HUMERUS 

consideration  to  the  condition  of  repair  in  the  fracture.  If  at 
the  end  of  three  weeks  union  is  found  to  have  begun,  it  will  be 
wise  to  move  the  shoulder  and  elbow  gently  by  passive  motion. 
The  seat  of  fracture  should  be  cautiously  guarded  against  move- 
ment during  these  gentle  manipulations.  A  little  gentle  passive 
movement  of  this  sort  repeated  occasionally  during  the  process 
of  repair  will  assist  very  considerably  in  the  restoration  of  the 
functional  usefulness  of  the  shoulder  and  elbow,  which  so  often 
become  stiff  from  immobilization. 

Prognosis. — Ordinarily,  union  occurs  readily  in  from  four 
to  six  weeks.  In  childhood  union  is  quite  solid  in  from  three 
to  five  weeks.  Fractures  of  this  bone  are  more  likely  to  be 
followed  by  nonunion  than  fracture  of  any  other  bone  in  the 
body.  The  presence  of  abnormal  mobility  after  a  considerable 
time  (three  months)  has  elapsed  is  the  sign  of  nonunion  by  bone. 
Considerable  muscular  atrophy  follows  this  fracture  (see  Fig. 
228).  Upon  using  the  arm  again  and  by  massage  the  size  of 
the  arm  is,  in  a  great  measure,  restored.  The  stiffness  of  the 
shoulder  and  elbow  which  is  sometimes  associated  with  this  in- 
jury is  due  to  long  immobilization  without  passive  motion. 

F  racture  of  the  shaft  of  the  humerus  sometimes  occurs  in  the  new- 
horn  during  delivery  or  afterward.  The  arm  is  best  immobilized 
by  thin  coaptation  splints.  These  splints  may  be  as  thin  as 
six  thicknesses  of  ordinary  letter  paper,  and  may  be  made  of 
cardboard.  The  humerus  is  completely  surrounded  by  them. 
They  are  held  firmly  by  adhesive-plaster  straps.  If  the}^  are 
cut  the  right  length  and  width,  they  may  be  applied  most  effi- 
ciently without  padding.  A  liberal  amount  of  drying  powder 
should  be  rubbed  on  the  arm  and  chest.  A  piece  of  compress 
cloth  should  be  placed  on  the  side  of  the  chest  under  the  injured 
arm,  to  prevent  chafing.  The  upper  arm  is  then  held  to  the 
side  of  the  chest  by  a  gauze  or  other  cloth  swathe.  Repair 
is  rapid.  Union  is  firm  in  about  three  weeks.  Fracture  of  the 
humerus  in  the  newborn  is  sometimes  associated  with  obstetrical 
paralysis  of  the  upper  extremity.  This  obstetrical  paralysis 
should  not  be  confounded  with  musculospiral  paralysis. 


MUSCULOSPIRAL    NE;rVE  IN    FRACTURE    OF   THE    HUMERUS   213 

The  MUSCULOSPIRAL  Nerve  in  Fracture  of  the  Humerus^ 
Injury  to  the  musculospiral  nerve  is  a  serious  accident,  and  it 
demands  careful  consideration.     It  is  a  lesion  that  is  overlooked, 


^^^ 


Fig.  229. — ^Relations  of  musculospiral  nerve  on  outer  side  of  arm  (from  dissected  specimen)  :  a. 
Acromion  ;  b,  deltoid ;  c,  trapezius ;  d,  triceps  ;  e,  musculospiral  nerve ;  /,  brachialis  anticus ;  g,  h, 
extensor  group ;  j,  humerus;   /.triceps;   ^.olecranon. 

and  is  often  discovered  unexpectedly.     Musculospiral  paralysis 

is  an  infrequent  complication  of  fracture  of   the  humerus  and 

occurs  chiefly  in  fractures  of  the  middle  third  of  the  bone;  less 

^  Sec  paper  Vjy  Scudder  and  Paul,  Annals  of  Surgery,  DeccmVjcr,  1909. 


214 


Fractures  of  the;  humerus 


frequently  it  occurs  in  fracture  of  the  lower  third,  and,  rarest  of  all, 
it  occurs  in  fracture  of  the  upper  third  of  the  humerus.     Musculo- 


Fig.  250. — Double  fracture  of  humeral  shaft.  Immediate  musculospiral  paralysis.  Union 
of  bones  in  six  weeks.  Operation  to  free  nerv'e  from  lower  fragment.  Sensation  and  motion 
returned.     Same  case  as  figure  232. 


Mk 

H 

^1^ "             ^^^^^^^^^^^^^1 

H^ 

[H'^l 

V^Z 

rf        1 

m 

^1 

Fig.  231. — Appearances  of    musculospiral   paralysis  foUcjuing    fracture  above   the   condyles  of 
the  humerus.     Note  the  wrist-drop  (after  Pedro  Chutro,  Buenos  Aires). 

Spiral  paralysis  occurs  in  from  4  to  8  per  cent,  of  the  cases  of  frac- 
ture of  the  humerus. 


MUSCULOSPIRAL   NERVE    IN   FRACTURE    OF   THE    HUMERUS    215 

It  is  possible  to  have  a  musculospiral  paralysis  in  a  case  of  fracture 
of  the  humerus  from  causes  entirely  independent  of  the  fracture. 

Moreover,  the  fracture  of  the  humerus  is  not  the  only  bone 
fracture  which  may  damage  the  musculospiral  nerve:  ulnar 
fracture  in  the  upper  third  has  been  attended  with  symptoms 
pointing  to  involvement  of  the  posterior  interosseous  nerve. 

Anatomical. — The  musculospiral  nerve  pursues  its  course 
through  the  upper  arm  in  close  relation  to  a  solid  structure — 
the  humerus — and  maintains  its  closest  relation  with  the  bone 


Loose  fragment  ot 
shaft. 


-  Condyle  of  humerus, 


Fig..  232. — Same  as  figure  233    Lateral  view  to  show  displacement  of  fragment  (X-ray 

tracing). 

and  periosteum  in  its  middle  third  (see  Fig.  229).  The  nerve  is 
not  imbedded  in  soft  tissues.  Moreover,  its  course  is  spiral,  thus 
subjecting  itself  peculiarly  to  traumata  resulting  from  displace- 
ment of  fragments. 

Before  the  nerve  enters  the  groove  or  just  about  at  that  point, 
it  gives  off  three  cutaneous  branches  which  are  described  as  sup- 
plying the  upper  arm;  these  branches  run  more  in  the  muscle 
tissue  and  preserve  their  function  in  the  large  majority  of  trau- 
matic paralyses  of  the  musculospiral. 


2l6 


IfRACTURES    OF    THE    HUMERUS 


Primary  and  Secondary  Paralysis. — Cases  of  musculospiral 
paralysis  associated  with  fracture  of  the  humerus  are  divided 
into  two  broad  divisions  (Riethus)  based  on  the  time  when 
symptoms  of  nerve  involvement  appear.  Thus  they  are:  (i) 
immediate  or  primary,  and  (2)  secondary. 

A  further  subdivision  of  the  primary  cases  is  made  into:  (a) 
the  nerve  is  damaged  by  the  injury,  (b)  the  nerve  is  damaged  by 
the  bone  (Goldstein) . 

The  symptoms  of  nerve  impairment  appear  immediately 
in  the  primary  cases  and  stress  is  laid  on  the  importance  of  ex- 


__  J Upper  fragment  of 

'  humerus. 

/ 

/ 
/ 
/ 

—I —  —  Middle  loose  fragment. 


Lower  fragment. 


Fig.  233. — Double  fracture  of  the  humerus.  Paralysis  of  the  musculospiral  nerve.  Im- 
mediate union  of  bone.  Suture  of  nerve  found  caught  between  fragments.  Gradual  recovery. 
Same  as  figure  232  (X-ray  tracing). 

amining  every  fractured  humerus  with  reference  to  neural  integrity. 
Many  times  after  the  recognition  of  paralysis  of  the  musculo- 
spiral nerve,  uncertainty  of  its  duration  has  had  to  be  admitted 
by  the  attending  surgeon. 

The  secondary  cases  are  those  in  which  musculospiral  paralysis 
develops  from  nerve  compression  or  stretching  during  the  course 
of  osseous  repair.  The  secondary  cases  are  further  divided  (Fess- 
ler)  into  (a)  those  occurring  during  the  primary  fracture  healing 
process,  and   (6)    those  subsequent  to  fracture  healing.     In  the 


MUSCULOSPIRAL   NERVE    IN    FRACTURE    OF   THE    HUMERUS    217 

latter  variety  necrosed  bone,  a  pseudo-arthritis,  or  a  fistulous 
tract  may  be  the  cause. 

Musculospiral  nerve  injury  may  complicate  fracture  of  the 
humerus  at  any  age,  and  has  been  known  to  occur  with  obstetrical 
fracture;  infants  and  adolescents  present  numerous  examples  of 
paralysis. 

Etiology. — The  principal  factor  in  the  etiology  is  the  anatom- 
ical relation  of  the  musculospiral  nerve  to  the  humerus,  especially 
in  the  middle  third  of  the  bone. 


Fig.  234.— One  year  after  suture  of  musculospiral  nerve.     Note  relaxed  position  of  hand.     (Massa- 
chusetts  General   Hospital   clinic.) 

In  the  primary  cases  coincident  with  or  immediately  following 
the  fracture,  the  nerve  may  be  contused,  stretched,  divided  par- 
tially or  completely,  pinched  between  the  fractured  ends,  or  be 
impaled  by  a  splinter. 

The  secondary  cases  are  comprised  largely  in  one  class,  namely, 
callus  inclusion  of  the  musculospiral  nerve,  which  by  pressure,  as 
is  generally  assumed,  impairs  the  function  of  the  nerve  till  even 
total  paralysis  is  developed ;  or  if  the  callus  gives  a  free  tunnel  for 
the  nerve  it  undergoes  stretching  to  a  degree  that  suspends  more 
or  less  completely  its  functions.  Even  if  the  nerve  is  not  included 
in  the  callus  tissue,  but  is  pushed  before  it,  the  course  of  the  nerve 
over  the  rounded  mass  may  result  in  a  stretching  with  loss  of 
function. 

Symptoms. — The     symptoms     of     musculospiral     involvement 


2l8  FRACTURES    OF   THE    HUMERUS 

at  the  time  of  fracture  or  during  repair  are  largely  of  motor 
impairment  or  loss.  The  forearm  extensor  muscles  controlling 
the  wrists  and  digits  lose  either  partially  or  completely  their 
power;  and  some  degree  of  anesthesia  may  be  established  in  the 
radial  nerve  supply.  Chiefly  the  sensory  loss  is  found  on  the 
dorsum  of  the  hand  between  the  metacarpal  bones  of  the  thumb 
and  forefinger,  the  so-called  "punctum  maximum"  of  anesthesia. 

In  general,  the  sensory  symptoms  have  no  relation  to  the 
degree  of  motor  loss.  It  is  said  (Fessler)  that  sensory  disturbance 
follows  primary  paralysis  only  and  that  secondary  paralysis  has  no 
sensory  disturbance. 

The  symptoms  are  largely  motor;  the  paralyzed  muscles  are: 
extensor  ossis  metacarpi  pollicis,  extensor  communis  digitorum, 


Fig.  235. — One  year  after  suture  of  the  musculospiral  nerve.     Note  powerful  extension  of  wrist.     (Case 
of  Dr.  H.  H.  A.  Beach,  Massachusetts  General  Hospital  clinic.) 

extensor  carpi  radialis,  extensor  carpi  ulnaris,  extensor  longus 
pollicis,  extensor  brevis  pollicis,  extensor  indicis,  extensor  minimi 
digiti,  and  supinator  longus  and  brevis. 

The  position  assumed  by  the  arm  and  hand  in  musculospiral 
paralysis  is  flexion  of  the  fingers  at  the  metacarpophalangeal 
joints  with  ulnar  abduction  and  slight  flexion  of  the  wrist;  the 
thumb  is  adducted  and  the  forearm  pronated  (see  Figs.  230,  231). 

In  primary  paralysis  or  paresis  the  onset  is  as  sudden  as  the 
break  of  the  bone.  The  secondary  cases  may  develop  insidiously 
with  formications  and  sharp  pains  along  the  nerve  and  functional 
failure  by  degrees  along  with  the  compression. 

No  definite  time  can  be  set  when  the  callus  interferes  with 
nerve  function,  but  in  a  general  way  it  is  in  the  second  week  or 
later.     It  is  important  to  ascertain  whether  a  period  of  preserva- 


MUSCULOSPIRAIv   NERVE    IN    ERACTURE    OF   THE    HUMERUS    219 

tion  of  function  of  the  nerve  immediately  follows  the  fracture. 
The  motor  and  sensory  disturbances  set  in  practically  simultane- 
ously in  secondary  cases  (Riethus). 

Trophic  disturbances  are  rare,  but  atrophy  may  occur,  and 
in  exceptional  cases  the  nails,  skin,  and  cellular  tissue  may  show- 
nutritional  deterioration. 

Callus  incarceration  of  the  musculospiral  with  total  paralysis 
may  be  attended  with  neuralgic  pain,  especially  on  movement. 


Fig.  236. — Note  the  situation  of  cicatrix  locating  lacerated  wound  of  upper  arm  which  damaged  muscu- 
lospiral nerve.     (Massachusetts  Genera!  Hospital  clinic.) 


From  callus  irritation  the  perineum  may  proliferate  in  a  spindle- 
like thickening,  forming  a  sort  of  neuroma.  On  the  other  hand, 
the  nerve  may  be  flattened  and  thinned. 

Prognosis. — The  prognosis  in  a  general  way  is  favorable  to 
recovery  in  the  lar^e  majority  of  cases  which  have  had  the  benefit 
of  operative  procedure.  According  to  Bruns  50  per  cent,  of  all 
cases  require  operation. 

Some  cases  have  been  operated  on  a  second  and  a  third  time. 
There  exist  records  of  cases  operated  on  sixteen  months  and  three 
and  a  half  years  after  fracture  with  restoration  of  nerve  function. 


220  FRACTURES    OF    THE    HUMERUS 

In  general,  the  longer  the  duration  of  paralysis  the  less  favorable 
the  prognosis. 

The  time  of  improvement  after  operation  varies  from  a  few 
weeks  or  even  days  to  months;  generally  it  begins  in  three  to  four 
months  and  final  cure  is  completed  in  about  a  year's  time.  One 
case  (Riethus),  with  resection  of  the  humerus,  recovered  in  two 
years,  improvement  setting  in  first  after  one  year. 

Cases  are  recorded  of  quick  return  of  sensation  in  one  day,  in 
two  days,  and  eight  to  ten  days  after  operation.  The  general 
law  seems  to  hold  true  for  the  musculospiral  that  sensation  re- 
turns before  motion  after  paralysis  of  both. 

Electrical  reactions  in  some  measure  are  of  prognostic  aid,  but 
their  value  is  limited  because  they  cannot  indicate  the  pathologic 
condition.  A  complete  reaction  of  degeneration  is  more  unfavor- 
able than  a  partial  one,  and  though  it  would  make  the  prognosis 
grave,  is  by  no  means  a  contraindication  to  operation.  But  a 
change  in  the  character  of  the  reaction  of  degeneration  is  perhaps 
of  most  significance,  being  unfavorable  when  the  negative  current 
response  of  the  muscle  is  less  than  the  positive.  Most  favorable 
is  the  presence  of  faradic  response  in  the  nerve,  which,  however, 
is  usually  subsequent  to  evidence  of  voluntary  return. 

Indications  for  Operation. — What  are  the  indications  for  opera- 
tion in  musculospiral  paralysis  complicating  fracture  of  the 
humerus  and  its  healing?  Every  case  of  paralysis,  whether  pri- 
mary or  secondary,  requires  careful  study  as  to  the  question  of 
operation.  The  pathological  condition  of  the  nerve  is  the  vital 
point,  and,  unfortunately,  similar  symptoms  may  attend  a  varied 
pathological  condition;  there  is  not  even  a  pathognomonic  symp- 
tom of  complete  division  of  the  nerve. 

Of  more  importance  than  the  fact  of  some  failure  of  function 
in  the  musculospiral  is  the  time  this  loss  of  function  has  persisted 
and  whether  it  is  getting  less  or  increasing.  Many  cases  have 
recovered  without  operation.  Many  other  cases  are  reported  in 
which  exploration  was  unnecessary;  if  primary  paresis  persists  and 
increases,  then  operate.  If  four  to  six  months  pass  without  im- 
provement, operation  should  be  resorted  to.  Secondary  paralyses 
never  recover  spontaneously,  so  that  operation  is  always  indicated 
in  this  class  of  case.     Moreover,  it  should  be  done  early,  though 


MUSCULOSPIRAIv   NEJRVE;    in   fracture    of   the;    humerus    221 

late  interference  has  proved  beneficial.  A  case  of  primary 
paralysis  should  not  be  operated  if  the  symptoms  are  not  in- 
creasing. 

The  Rontgen  ray  has  been  of  service.  First  of  all,  it  demonstrates 
the  position  of  the  bones.  Good  alignment  would  assure  the  sur- 
geon that  the  nerve  was  not  on  a  stretch  continuously.  A  large 
shadow  of  callus  would  be  of  corroborative  value  in  secondary 
cases.  The  information  as  to  the  nerve  is  indirect,  for,  after  all, 
we  have  to  infer  what  may  have  happened  to  the  nerve  from  what 
is  found  as  to  the  condition  and  position  of  the  bone. 


Fig.  237. — ^'Note  ununited  humerus  twelve  years  after  injury.  Muscles  seen  in  powerful  contrac- 
tion. When  muscles  are  at  rest  the  arm  hangs  straight  at  the  side.  Wrist-drop  islstill  present.  ("Mas- 
sachusetts General  Hospital  clinic.) 

The  results  of  electrical  findings  are  of  some  aid  in  demonstrat- 
ing the  degree  of  paralysis  present,  and  may  be  of  the  greatest 
help  in  determining  functional  restoration  or  impairment.  But  the 
pathological  condition  and  the  pathological  future  of  the  nerve  are 
the  essentials  to  be  determined  as  nearly  as  possible;  and  the 
knowledge  of  the  electrical  reactions  helps  only  a  little.  A  con- 
tusion cannot  be  distinguished  by  the  electrical  reaction  from 
damage  due  to  callus  or  even  a  complete  division  of  the  nerve. 

In  the  treatment  of  these  cases  the  question  of  operation  requires 
conservative   consideration.     If  a  given  case  is  going  to  get  well 


222  FRACTURES    OF   THE    HUMERUS 

with  treatment  other  than  resection,  suture,  or  operative  release 
of  the  nerve,  operative  interference  is  not  required.  On  the  other 
hand,  if  permanent  paralysis  of  the  extensors  is  inevitable  unless 
the  musculospiral  nerve  is  dealt  with  surgically,  operative  proced- 
ure is  demanded.  But  such  definite  knowledge  is  not  attainable 
in  every  case.  In  the  consideration  of  individual  cases  we  should 
approximate  as  nearly  as  possible  this  ideal  attitude  before 
rendering  an  opinion  as  to  operation. 

A  careful  operation,  even  if  unnecessary,  would  not  interfere 
materially  with  ultimate  recovery,  while  an  error  in  failing  to 
operate  would  be  most  regretable.  So  it  seems  advisable,  on  the 
whole,  to  favor  surgical  investigation  in  cases  in  which  doubt  exists. 

The  time  of  operation  is  to  be  chosen  at  as  early  a  date  after 
symptoms  of  paralysis  appear  as  possible.  The  later  degenerative 
changes  in  both  nerve  and  muscle  are  thus  reduced  to  a  minimum; 
and  the  progress  of  a  partial  but  increasing  paralysis  may  be 
arrested. 

Indications  for  or  against  operative  procedure  turn  on  the  patho- 
logical diagnosis.  The  more  severe  the  trauma  the  greater  the  prob- 
ability of  some  tearing  through  the  nerve  or  even  complete  division, 
especially  if  there  has  been  much  rotation  of  the  peripheral  frag- 
ment, or  it  has  been  for  a  moment  pulled  apart  from  the  proximal 
fragment,  or  the  two  fragments  have  been  displaced  out  of  line  or 
at  an  angle;  and  in  such  a  position  the  nerve  on  the  stretch  may  be 
worn  through  by  an  edge  of  bone.  Such  conditions,  as  well  as 
that  of  being  caught  between  the  fractured  surfaces  and  transfix- 
ion by  a  splinter  of  bone,  are  among  the  rarer  complications 
pathologically;  but  if  they  exist,  operation  is  imperatively  re- 
quired at  an  early  stage. 

If  in  primary  paralysis  of  the  musculospiral  attending  fracture 
of  the  humerus  the  anatomical  continuity  of  the  nerve  is  assured, 
nature  can  be  relied  on  to  restore  function,  provided  that  the 
tension  on  the  nerve  is  not  abnormal  and  compression  by  new 
tissue  is  not  superimposed  in  the  process  of  repair.  Good  and 
gentle  adjustment  of  the  bony  fragments  largely  insures  against 
the  nerve  being  kept  on  the  stretch  continuously.  The  complica- 
tion of  callus  compression  cannot  be  specially  guarded  against. 
If  partial  recovery  of  a  primary  paralysis  is  followed  by  a  recurrence 


MUSCULOSPIRAIv   NERVE    IN    FRACTURE    OF    THE    HUMERUS    223 

of  the  paralysis  during  callus  formation,  we  should  then  have  to 
consider  it  a  case  of  secondary  paralysis. 

Secondary  paralysis  of  the  musculospiral  embrace  the  larger 
number  of  cases.  A  partial  and  moderate  paralysis  not  increasing 
and  with  a  partial  reaction  of  degeneration  offers  the  best  chance 
for  restoration  of  the  nerve  without  operation.  Again,  if  a 
stage  of  improvement  sets  in,  it  would  be  wise  not  to  interfere 
surgically,  but  try  to  cause  absorption  of  the  callus  and  cicatrix 
by  massage  and  electricity  so  as  to  free  the  nerve  (Neugebauer) . 


Fig.  238.— Note  left  wTist-drop  sixteen  years  after  accident.     Xote  atrophy  of  forearm  and  tand 
muscles.     (A'lassachusetts    General    Hospital  clinic.) 


Increasing  paralysis,  however,  especially  if  it  becomes  complete, 
justifies  surgical  exploration  or,  rather,  demands  it.  Moreover, 
a  condition  of  paralysis  that  is  stationary  would  indicate  opera- 
tion. 

In  primary  cases  a  divided  nerve  is  to  be  sutured;  if  any  con- 
dition is  found  that  keeps  the  nerve  on  a  stretch,  readjustment  of 
the  bone  fragments  is  indicated;  if  the  nerve  is  caught  between 
bony  surfaces  it  is  to  be  made  free,  and  impaling  splinters  should 
be  removed.  Resection  of  the  humerus  may  be  necessary  to 
approximate  nerve  ends.  In  all  cases  a  proper  bed  for  the  nerve 
must  be  provided. 


224 


FRACTURES    OF   THE    HUMERUS 


The  secondary  cases  have  received  more  attention  by  ingenious 
operators  in  their  efforts  to  prevent  repetition  of  compression. 
In  most  cases  a  clear  channel  is,  to  be  sure,  made  for  the  nerve 
by  simply  removing  compressing  tissue.  Laterally,  however,  the 
nerve  has  been  further  safeguarded  by  adjusting  soft  tissues, 
muscle,  fat,  or  fasciae  about  the  nerve  in  such  a  way  as  to  render 
impossible  recurrent  callus  enclosure  and  pressure. 


Fig.  23p. — Xote  atrophy  of  shoulder  and  upper  arm  iiiumIl-t  on  the  left  side  sixteen  years  following 
unsuccessful  suture  of  musculospiral  nerve.     (Massachusetts  General  Hospital  clinic.) 


Just  what  the  detailed  operative  procedure  in  both  primary 
and  secondary  paralyses  will  be  cannot  be  determined  before- 
hand unless  the  operator  obtains  an  accurate  conception  of  the 
pathological  conditions. 

In  an  analysis  of  the  Massachusetts  General  Hospital  cases  the 
following  facts  are  of  importance: 

There  is  a  total  of  1 1  cases  in  which  the  end -results  are  known. 
The  important  facts  in  these  cases  are  tabulated.  In  the  table 
are  placed  the  cases  showing  the  time  that  elapsed  between  the 


MUSCULOSPIRAL  NERVE  IN  FRACTURE  OF  THE  HUMERUS  225 

date  of  operation  and  the  accident  and  between  the  date  of  oper- 
ation and  the  last  observation  of  the  patient,  together  with  the 
functional  result  recorded  at  the  last  examination. 


CASES    OF    MUSCULOSPIRAL    PARALYSIS,   MASSACHUSETTS    GENERAL 
HOSPITAL  CLINIC 

(Tabulated   according  to   time   elapsed.) 


No. 


Date  of 
accident. 


Date  of  operation. 


Interval 
between 
accident 

and 
operation. 


Result  and  date  of  last 
observation. 


Interval 
between 
operation 
and  final 
observation. 


May  I,  1901. . 

Dec.  16,  1896. 

Jan.,  1903 

Oct.  II,  1905. 
Aug.  5,  1897-  • 


Sept.  21,  1901. 


April,  1900. 
July,  1893.  . 


Nov.  27,  1905. 

Oct.,  1890 

Nov.,  1899  . . . 

March  2,  1899 


May  22,  1897 

April  7,  1903 

Jan.  18,  1906 

(i)  July,  1900 

1(2)  August,  1900. 
[(3)  July,  1901. 

July,  1900 

!(i)  Dec,  1893,  bone, 

(2)  Feb.,  1S95,  nerve, 

(3)  Feb.,  1S90,  bone, 

(4)  Feb.,  1907,  bone, 
Dec.  16,  1905 


Feb.  21,  1891. 
June,  1890.  .  . 


April  27,  1899. 


4^  months, 

S  months. 

3  months. 

3  months. 

3  years. 


3  months. 

I  year, 
7  months. 


3  weeks. 

4  months. 
7  months. 

3  weeks. 


Sept.,  1902.  No  wrist-drop.  Im- 
proving  

Dec.  1906.      Excellent  result 

March,  190S.     Perfect  result.  .  . .  . . 

Jan.,  1907.     Perfect  result 

1907.  Good  functional  result. 
Movements  about  half  normal.  . . 

Oct.,  1903.     No  improvement 

Feb.,  1907.     Marked  wrist-drop.  .  . 

Dec,  1906.  Perfect  functional  re- 
sult  

April,  1907.     Wrist-drop  complete. 

Dec,  1906.  Fair  result.  Exten- 
sion of  wrist  possible 

Nov.  22,  1900.  Perfect  result,  ex- 
cept extension  of  thumb 


I  year. 
9  years. 
5  years. 
I  year. 

7  years. 

3  years. 
12  years. 


I  year. 
16  years. 

16  years. 

I  year, 

7  months. 


Eight  cases  of  the  11  have  no  wrist-drop  at  present.  Three 
cases  showed  no  improvement  in  the  nerve  function  following 
operative  interference. 

Of  these  3  cases,  i  died  three  years  following  suture  of  the  nerve, 
showing  no  improvement  in  the  nerve  function;  another  has  had 
three  unsuccessful  operations  for  ununited  fracture  of  the  humerus 
at  intervals  of  six  to  eight  years;  the  third  case  had  at  the  first 
operation  the  nerve  freed,  resected,  and  sutured,  and  at  the  second 
operation  the  bone  shortened  by  resection,  the  nerve,  found  bulbous, 
resected  and  sutured.  After  sixteen  years  there  is  no  return  of  func- 
tion in  the  nerve. 

Eight  of  these  cases  were  badly  injured.  The  trauma  was 
very  severe;  the  arm  was  caught  in  the  shafting  or  the  belt  of  an 
engine,  or  had  received  a  gunshot  wound,  or  was  crushed  by 
machinery.  Most  all  the  cases  were  operated  upon  some  three  or 
four  months  following  the  accident.  The  longest  interval  between 
accident  and  operation  was  three  years.  This  case  recovered  func- 
15 


226  FRACTURES    OF   THE    HUMERUS 

tional  usefulness  and  the  musculospiral  supply.  Improvement 
in  these  cases  was  first  noted  six  months  to  one  year  following  the 
operation. 

Facts  of  Importance  Concerning  Musculospiral  Paralysis. 
— Musculospiral  paralysis  occurs  in  from  4  to  8  per  cent,  of  cases 
of  fracture  of  the  humerus. 

Fracture  of  the  middle  third  of  the  humerus  is  the  fracture 
most  commonly  complicated  by  musculospiral  paralysis. 

Fracture  of  the  humerus  at  any  age  may  be  associated  with 
musculospiral  paralysis. 

Musculospiral  paralysis  is  primary  if  it  dates  from  the  accident, 
and  it  is  secondary  if  it  is  subsequent  to  the  accident. 

Primary  paralysis  of  the  musculospiral  nerve  indicates  a  more 
severe  injury  to  the  nerve  than  does  secondary  paralysis. 

The  diagnosis  of  the  exact  pathological  condition  of  the  musculo- 
spiral nerve  following  trauma  to  it  is  of  the  greatest  importance  and 
is  difficult  to  determine. 

Progressive  impairment  of  function  or  stationary  paralysis  of 
the  musculospiral  nerve  complicating  fracture  of  the  humerus 
justifies  and  may  demand  operation. 

Operation  means  the  release  of  the  nerve  from  compression 
or  tension  and  often  resection  and  suture,  and  always  guarding 
against  recurrent  compression  or  stretching. 

A  late  suture  (months  after  the  injury)  is  attended  by  technical 
operative  difficulties  not  present  in  an  early  suture  (soon  after  the 
injury). 

Resection  of  the  humerus  to  allow  of  approximation  of  the 
divided  ends  of  the  musculospiral  nerve  is  a  good  procedure  (Allis), 
but  not  until  nerve  suture  a  distance  has  first  been  carefully  em- 
ployed. 

Electrical  reactions  cannot  determine  the  pathological  condi- 
tion.    They  are  of  value  in  determining  the  course  of  events. 

The  prognosis  after  operation  is  good;  the  earlier  a  necessary 
operation  is  done  the  speedier  the  cure. 

Exercise  of  paralyzed  muscles  by  electric  stimulation  (galvan- 
ism) is  helpful. 

Sensory  symptoms  are  variable;  in  general  the  sensory  symp- 
toms have  no  relation  to  the  degree  of  motor  loss. 


EXAMINATION    OF   THE    ElyBOW 


227 


FRACTURES  OF  THE  ELB017 
Fractures  of  the  lower  end  of  the  humerus  near  to  and  involving 
the  elbow-joint  are  frequent  in  childhood,  but  much  less  fre- 
quent in  adults.  A  familiarity  with  the  bony  landmarks  of 
the  elbow  is  essential  to  an  accurate  diagnosis.  The  more  nearly 
accurate  the  diagnosis,  the  more  efficient  will  be  the  treatment 


External  condyle. 


Radial  head., 


Internal  condyle. 


Olecranon  process 
of  the  ulna. 


Fig.  240.— Note  the  bony  relations  of  the  internal  and  external  condyles  of  the  humerus 
and  the  olecranon  process  of  the  ulna  in  complete  extension  of  the  forearm.  The  three  points 
are  almost  in  a  straight  line. 


and  the  more  intelligent  will  be  the  prognosis.  Every  elbow 
injury,  no  matter  how  trivial,  should  be  examined  under  anes- 
thesia. 

Method  of  Examination. — The  normal  anatomical  relations 
of  the  uninjured  elbow  are  to  be  first  determined.  The  large 
prominent  internal  condyle  of  the  humerus,  the  olecranon  pro- 
cess of  .the  ulna,  the  external  condyle,  the  head  of  the  radius,  are 
each  in  turn  to  be  grasped  by  the  thumb  and  forefinger.    If  these 


2  20  FRACTURES    OF    THE    HUMERUS 

bony  points  can  be  recognized  upon  the  injured  elbow,  then  a 
fracture  ought  not  to  be  overlooked. 

The  Three  Bony  Points  of  the  Elbow  Region:  With  a  pencil 
or  ink  the  internal  and  external  condyles  of  the  humerus  and 
the  tip  of  the  olecranon  should  be  marked,  the  forearm  being 
extended.  Normally,  these  three  points  will  be  found  to  be 
in  nearly  a  straight  line  transverse  to  the  long  axis  of  the  limb. 
The  tip  of  the  olecranon  is  a  trifle  above  this  line  (see  Figs.  240, 
241,  242). 

Palpation  of  the  Three  Bony  Points:    Grasping  the  left  wrist 


Olecranon  fossa. 


External  co>idvle. Wk^i.  f  ^        ^  -^ .Internal  condyle, 


Olecranon  process. 

Fig.  241. — Note  the  bony  relations  of  the  internal  and  external  condyles  and  olecranon 
process  of  the  ulna  when  the  forearm  is  flexed  to  a  right  angle.  The  three  points  make  a 
triangle  and  lie  in  a  plane  parallel  with  posterior  surface  of  humerus. 

with  the  left  hand,  place  the  right  thumb  upon  the  external 
condyle,  the  third  finger  on  the  internal  condyle,  and  the  fore- 
finger on  the  olecranon.  When  the  elbow  is  at  a  right  angle, 
these  three  points  will  be  found  in  the  same  plane  with  the 
back  of  the  upper  arm.  A  similar  examination  may  be  made 
of  the  right  elbow,  changing  hands  for  convenience  (see  Figs. 
240,  243) . 

The  Head  of  the  Radius  (see  Fig.  246) :  Grasping  the  elbow 
with  one  hand,  the  thumb  resting  one-half  an  inch  below  the 
external  condyle  upon  the  head  of  the  radius,  and  holding  the 
wrist  in  the  other  hand,  the  patient's  forearm  is  pronated  and 


EXAMINATION    OF   THE   ELBOW 


229 


supinated.  If  the  shaft  of  the  radius  is  unbroken,  the  head  ot 
the  radius  will  be  felt  to  move  under  the  thumb. 

The  Carrying  Angle  (see  Figs.  244,  245) :  The  lateral  angle 
that  the  supinated  forearm  makes  with  the  upper  arm  is  called 
the  carrying  angle.  It  is  important  to  remember  that  this 
angle  varies  normally  within  very  wide  limits.  Some  individuals 
have  no  carrying  angle.  Its  presence  or  absence  is  of  little 
functional  value. 

Movements  at  the  Elbow-joint:  The  movements  of  the  joint 


Fig.  242.— -N'ormal  elbow.     Relation  of  the  three  bony  points  in  almost  complete  extension  of 
forearm.     Prominence  of  olecranon  and  two  condyles  evident. 

should  be  determined  both  in  flexion  and  extension.  There  is 
normally  no  lateral  motion  in  the  extended  elbow-joint.  Ab- 
normal lateral  motion  in  either  adduction  or  abduction  should 
be  detected  if  present. 

Measurements:  The  distance  between  the  two  condyles  should 
be  measured  on  the  uninjured  arm.  The  distance  from  the 
acromial  process  to  the  external  condyle  of  the  humerus  should 
also  be  measured  (see  Fig.  168). 

Having  then  established  a  standard  of  comparison  in  the 
normal  elbow,  the  injured  elbow  should  be  examined  with  the 


Fig.  243. — Normal  elbow.     Examination.     The  three  bony  points.     Note  position  of  the 
thumb  and  two  fingers  of  the  examining  hand. 


Fig.  244. — Normal  elbows.    Well-marked  carrying  angle  apparent. 
230 


EXAMINATION    OF    THE    ELBOW 


231 


greatest  care.  Even  when  there  is  great  swelHng  of  the  elbow 
region,  steady  pressure  will  enable  the  fingers  to  reach  the  con- 
dyles. In  approaching  an  injury  to  the  elbow  the  questions 
which  arise  are:  Is  there  a  dislocation?  Is  there  a  fracture? 
Are  both  dislocation  and  fracture  present?  Is  there  a  contusion 
and  a  sprain?  Is  there  a  subluxation  of  the  radial  head?  In 
the  absence  of  positive  signs  of  dislocation,  subluxation,  and 
fracture  the  lesion  is  a  sprain  or  contusion.     In  the  absence  of 


Fig.  245.. 


-Position  of  supination,  showing  the  carrying  angle.     The  outline  shows  the  position 
of  pronation  with  disappearance  of  the  carrying  angle. 


positive  signs  of  dislocation  and  radial  subluxation  a  fracture 
will  be  present. 

Summary  of  the  Order  of  Examination  of  the  Injured  Elbow. — 
Notice  whether  the  swelling  and  ecchymosis  are  general  or  local- 
ized. If  localized,  that  may  determine  the  seat  of  the  lesion. 
Observe  the  carrying  angle.  Palpate  the  external  and  internal 
condyles  (see  Fig.  247),  the  olecranon  process  of  the  ulna  (see 
Fig.  210),  and  the  head  of  the  radius  (see  Fig.  246).  Deter- 
mine if  crepitus  is  present.     See  if  the  head  of  the  radius  rotates. 


232 


FRACTURES   OF  THE   HUMERUS 


Note  the  relations  of  the  three  bony  points,  with  the  forearai 
flexed  at  a  right  angle  and  completely  extended  (see  Figs.  240, 
241,  242,  243).  Note  any  lateral  motion  at  the  elbow -joint  (see 
Fig-  249).  Determine  the  possible  movements  of  the  elbow- 
joint.     Make  measurements. 

The  traumatic  lesions  of  the  elbow  may  be  grouped,  for  sim- 
plicity and  ease  of  reference,  in  the  following  manner.     During 


Fig.  246. — Normal  elbow.      Method  of  examination.     Palpating  head  of  radius.     Spot  marks 

external  condyle. 


the  routine  examination  it  is  wise  to  have  in  mind  these  possible 
individual  lesions: 

Lesions  of  the  Radius  and  Ulna:  (a)  Dislocation  of  the  radius 
and  ulna  backward  with  or  without  fracture  of  the  coronoid 
process  of  the  ulna. 

(b)  Subluxation  of  the  radial  head. 

(c)  Fracture  of  the  olecranon  process  of  the  ulna. 
Cd)  Fracture  of  the  neck  or  head  of  the  radius. 


Fig.  247.— Normal  elbow.     Method  of  examination.     Grasping  the  two  condyles  of  the 

humerus. 


Fig.    248. — Normal  elbow.     Method  of  examination.     Palpating  olecranon. 
2.33 


234 


FRACTURES    OF   THE    HUMERUS 


Lesions  of  the  Lower  End  of  the  Humerus:  (e)  Fracture  of 
the  internal  epicondyle. 

(/)  Fracture  of  the  internal  condyle. 

(g)  Fracture  of  the  external  condyle. 

(/?)  Transverse  fracture  of  the  shaft  of  the  humerus  above 
the  condyles  (supracondyloid). 

(i)  Separation  of  the  lower  epiphysis  of  the  humerus. 

(k)  T-fracture  into  the  elbow-joint. 

Symptoms  of  Lesions  About  the  Elbow- joint  with  the  Differential 


Fig.  249- 


-Normal  elbow.     Line  between  the  condyles.     Method  of  examining  for  supracon- 
dyloid fracture. 


Diagnosis  of  Each  Lesion. — (a)  A  Dislocation  of  the  Radius  and 
Ulna  Backward  with  or  without  Fracture  of  the  Coronoid  Pro- 
cess of  the  Ulna :  There  may  be  very  great  swelling  of  the  region 
of  the  elbow.  The  relations  between  the  three  bony  points  are 
disturbed.  The  olecranon  process  is  very  prominent  posteriorly. 
The  radial  head  is  displaced  backward.  The  two  condyles  are 
far  in  front  of  the  olecranon.  There  is  abnormal  lateral  mobility. 
The  normal  movements  of  the  joint  are  restricted.  This  in- 
jury may  be  mistaken  for  a  supracondyloid  fracture.     The  im- 


DIAGNOSIS    OF*    BLBOW -JOINT   LESIONS 


235 


portant  difference  has  been  mentioned.  A  dislocation  of  both 
bones  backward,  if  reduced,  does  not  ordinarily  tend  again  to 
become  displaced;  if  it  does,  there  is  most  likely  a  fracture  of 
the  coronoid  process  of  the  ulna. 


Fig.  250. — Lower  end  of  humerus,  ante- 
rior surface.  Note  lines  of  fracture  of  in- 
ternal epicondyle  and  of  fracture  of  exter- 
nal condyle. 


Fig.  251. — Lower  end  of  humerus,  ante- 
rior surface.  Note  lines  of  supracondyloid 
fracture  and  of  fracture  of  internal  condyle. 


Fig.  252. — Lower  end  of  humerus,  anterior 
surface.     Note  lines  of  T-fracture. 


Fig.  253. — Lower  end  of  humerus,  pos- 
terior surface.  Note  olecranon  fossa  and 
trochlear  surface  for  ulna.  Note  projec- 
tion of  internal  condyle. 


(6)  Subluxation  of  the  Head  of  the  Radius:  This  takes  place 
in  children  under  five  years  of  age.  It  is  due  to  sudden  traction 
upon  the  extended  forearm,  which  so  often  occurs  in  lifting  a 
child  by  the  arm  over  a  curbstone.     The  child  presents  the  arm 


236 


FRACTURES    OF   THE   HUMERUS 


hanging  slightly  away  from  the  side,  with  the  elbow  a  little 
flexed  and  the  hand  semipronated.  Attempts  to  use  the  arm 
cause  pain.  The  extremes  of  flexion  and  extension  and  supina- 
tion are  painful.  Inspection  will  detect  a  slight  swelling  one- 
half  of  an  inch  to  an  inch  below  the  external  condyle  of  the 
humerus.     Tenderness  is  present  over  the  head  of  the  radius. 


Fig-  254. — Fracture  of  the  internal  condyle.    Recovery  with  "  gunstock  "  deformity,  due  to 
slipping  upward  of  fragment  and  adduction  of  forearm. 


The  relation  of  the  three  bony  prominences  is  preserved.  The 
details  of  this  not  uncommon  lesion  are  mentioned  because  it  is 
sometimes  mistaken  for  a  fracture  of  the  radial  head  or  a  simple 
sprain  of  the  elbow.  A  fracture  of  the  radius  below  the  neck 
has  also  been  mistaken  for  this  subluxation  of  the  head.  Careful 
detailed  examination  will  alone  clear  up  any  doubts. 

(c)   Fracture   of  the    Olecranon    Process:  The   details   of  this 


DIAGNOSIS   OF   ELBOW -JOINT   LESIONS 


237 


fracture  are  considered  elsewhere.     Crepitus  and  mobility  of  the 
olecranon  fragment   will   be  felt.     There   may  or  may  not   be 


Capitellum. J ^]|^ 

Radius. 1 


--^ Internal  condyle. 

\ 
\ 


Fig.   255. — Normal  right  arm  of  patient  in  figure  247  (X-ray  tracing). 


Internal  condyle. 


—External  condyle. 

Capitellum. 


Radius. 


Fig.  2  5^; — Fracture  of  internal   condyle  of  left  humerus.      Recovery  with  deformity.     See 
figure  254  (X-ray  tracing). 


separation  of  the  fragments.  If  there  is  a  separation,  it  will 
be  detected  and  the  three  bony  points  will  have  their  normal 
relations  disturbed. 


238 


FRACTURES    OF    THE    HUMERUS 


(d)  Fracture  of  the  Neck  or  Head  of  the  Radius:  This  is  un- 
common. SwelHng  over  the  radial  head  and  neck  is  present. 
Supination  and  pronation  are  painful  and  limited  and  attended 
by  crepitus,  muscular  spasm,  and  possibly  a  loss  of  rotation  of 
the  radial  head. 

(e)  Fracture  of  the  Internal  Epicondyle:  The  epiphysis  of 
this  epicondyle  unites  to  the  shaft  of  the  humerus  between  the 
eighteenth  and  twentieth  years.  This  fracture  is  quite  common 
among  little  children.  If  this  fracture  presents  a  small  frag- 
ment, it  is  of  little  consequence.  If  a  large  fragment  is  broken 
off,  it  is  of  consequence.  The  displacement  is  downward  and 
forward.  The  ulnar  nerve  is  sometimes,  though  rarely,  im- 
plicated in  this  injury. 

(/)  Fracture  of  the  Internal  Condyle:  Swelling  over  this  con- 
dyle is  marked.  B}^  grasping  the  condyle  abnormal  mobility 
and  crepitus  are  detected  between  the  fragment  and  the  shaft. 
The  inner  of  the  three  bony  points  is  displaced  upward.  Lateral 
mobility  of  the  elbow  is  present;  adduction  is  especially  free. 
The  carrying  angle  will  be  diminished  if  there  is  displacement 
of  the  condyle  upward  (see  Figs.  254,  255,  256). 

(g)  Fracture  of  the  External  Cond3'le  (see  Fig.  270) :  Swelling 
over  this  condyle  is  marked.  Crepitus  and  abnormal  mobility 
are  present.  The  normal  relations  of  the  three  bony  points 
are  disturbed.  The  external  condyle  is  displaced  upward. 
The  relation  of  the  external  condyle  and  the  head  of  the  radius 
is  undisturbed.  Lateral  motion  at  the  elbow  is  or  is  not  present. 
The  transverse  measurement  of  the  elbow  is  greatest  on  the 
injured  side.     Supination  will  be  somewhat  limited. 

(h)  Transverse  Fracture  of  the  Shaft  of  the  Humerus  Above 
the  Condyles.  Supracondyloid  Fracture  (see  Fig.  271):  The 
line  of  this  fracture  is  higher  up  on  the  shaft  than  the  line  of 
the  epiphysis.  A  fullness  will  be  noticed  in  front  of  the  elbow- 
joint,  and  posteriorly  the  point  of  the  elbow  will  appear  prom- 
inent. The  small  lower  fragment  is  displaced  backward  with 
the  bones  of  the  forearm;  the  upper  fragment  or  shaft  of  the 
humerus  is  displaced  forward,  causing  the  fullness  in  the  bend 
of  the  elbow  (see  Fig.  274).  The  three  bony  points  maintain 
their  normal  relations.     This  distinguishes  the  fracture  from  a 


p,-g_  257.— Transverse  fracture  through  the  lower  end  of  the  humerus  at  level  of  olecranon  fossa. 
Anteroposterior  view.     Slight  displacement. 


Fig.  258.— Same  as  Fig.    257-    Lateral  view.     Slight  displacement. 


239 


240 


FRACTURES    OF    THE    HUMERUS 


dislocation  of  both  bones  backward  (see  Fig.  275).  Crepitus 
will  be  detected  upon  grasping  the  arm  firmly  above  and  below 
the  elbow-joint  (see  Fig.  249),  Recurrence  of  the  displace- 
ment often  follows  its  correction  unless  the  fracture  is  properly 
immobilized.  Reduction  of  this  fracture  may  be  most  difficult 
(see  Treatment,  p.  254).  Abnormal  lateral  and  anteroposterior 
mobility  above  the  elbow- joint  is  found  (see  Figs.  271,  272). 

(i)  Separation  of  the  Lower  Epiphysis  of  the  Humerus:  The 
lower  epiphysis  of  the  humerus  unites  to  the  shaft  about  the 
seventeenth  year.  It  includes  only  the  very  lowest  end  of  the 
humerus.     The    lower    epiphysis    of   the    humerus    is    made    up 


Humerus. 


Ulna 


Radius. 


Fig.  259. — Fracture  of  the  internal  condyle  ;  displacement  upward  of  fragment ;  union  in  dis- 
placed position — consequent  permanent  adduction  of  forearm  (after  Helferich). 


of  the  external  epicondyle,  the  capitellum,  and  the  trochlea. 
These  separate  centers  of  ossification  unite  about  the  thirteenth 
year,  and  at  about  the  seventeenth  year  they  join  the  shaft  of 
the  bone.  The  epiphysis  of  the  internal  epicondyle  is  entirely 
separate  from  the  large,  general,  lower  humeral  epiphysis.  It 
is  therefore  possible  to  have  a  complete  separation  only  after 
the  thirteenth  year. 

(7)  Injury  to  the  Lower  Epiphysis  of  the  Humerus :  This  is  a 
not  uncommon  accident.  It  occurs  usually  in  children  under  ten 
years  old.     There  is  no  change  in  the  relations  of  the  three  bony 


DIFFKRENTIAL    DIAGNOSIS 


241 


points.  It  somewhat  resembles  transverse  fracture  above  the 
condyles.  The  diagnosis  is  made  upon  the  following  points :  The 
age  of  the  individual ;  the  history  of  the  accident ;  the  existence  of 
abnormal  mobility  at  a  very  low  level  on  the  humeral  shaft; 
anteroposterior  mobility  very  marked,  lateral  mobility  being  less 
marked;  muffled  crepitus  (this  term  is  very  suggestive,  and  is 
used  by  Poland).  The  breadth  of  the  lower  end  of  the  humeral 
fragment  is  broader  than  in  the  case  of  a  fracture  (see  Figs.  276  to 
283  inclusive).  In  old  injuries  of  this  kind  there  is  usually  dis- 
covered a  very  considerable  thickening  of  the  lower  end  of  the 


Radius. 


Fig.  260. — Fracture  of  the  external  condyle  ;  union  with  fragment  displaced  upward,  resulting 
in  permanent  abduction  of  forearm  (after  Helferich). 


humeral  shaft.     This  is  due  to  the  deposit  of  new  bone  through- 
out the  area  of  denuded  periosteum. 

(k)  T-fracture  into  the  Elbow-joint  (see  Figs.  285,  286,  287):  The 
traumatism  which  causes  this  injury  may  be  extremely  slight. 
If  the  two  condyles  are  grasped,  crepitus  and  abnormal  mobility 
will  be  detected.  The  relations  of  the  three  bony  points  will  be 
disturbed,  according  as  one  or  both  condyles  are  displaced.  The 
transverse  measurement  of  the  condyles  will  be  found  to  be  in- 
creased. There  will  be  abnormal  lateral  mobility,  both  in  ad- 
duction and  abduction. 

16 


Fig.  261. — Internal  epicondylar  fracture. 


Fig.  262. — Note  displaced  epicondyle. 


Fig.  263. — Epicondylar  fracture. 


Fig.  264. — Epicondylar  fracture. 


Fig.  265. — Displaced  fragment  of  epicondylar  fracture 
with  dislocation  of  forearm  backward. 
242 


DIFFERENTIAL    DIAGNOSIS 


243 


Fig.  266.— Fracture  of  external  condyJe.  Fig.  267.— Fracture  of  external  condyle. 


Fig.  268. — Fracture  of  external 
condyle.  Capitellum  displaced. 


Fig.   269. — Fracture  of  external  condyle.     Capitellum  dis- 
placed. 


A  systematic  anatomical  examination  of  injuries  to  the  elbow 
under  an  anesthetic  will  overcome  much  of  the  indefiniteness 
that  surrounds  these  injuries.  A  crushed  elbow,  feeling  to  the 
examining  hand  like  a  bag  of  bones,  can  not  always  be  accurately 
diagnosed,  some  of  the  details  of  the  lesions  naturally  remain- 
ing undetermined.  The  Rontgen  ray  in  these  doubtful  cases 
will  be  of  material  assistance.  The  importance,  however,  of 
making  such  a  careful  eliminative  examination  as  is  described, 
both  from  the  point  of  view  of  treatment  and  prognosis,  can 
not  be  overestimated. 


244 


FRACTURES    OF    THE    HUMERUS 


Treatment. — The  object  of  treatment  is  to  restore  the  elbow- 
joint  to  its  normal  condition.     If   the  fracture   is  attended  by 


^4 1 External  condyle. 

I  — ^ — i Capitellum. 

1 Upper  radial  epiphysis. 


Fig.  270. — Fracture  of  external  condyle  of  humerus.    Child  five  years  of  age.    Nucleus  for 
capitellum  seen  below  fragment. 


Fig.  271. — Case  of  transverse  fracture  above  the  condyles  of  the  left  humerus ;  characteristic 
deformity.     The  anterior  deformity  is  higher  than  in  a  case  of  dislocation  of  the  elbow. 


great  swelling,  it  will  be  necessary  to  temporarily  support  the 
arm  until  the  swelling  reaches  its  maximum  and  begins  to  sub- 
side.    The  right-angle  internal  angular  splint  is  the  most  satis- 


Fig.  272. — Transverse  fracture  above  the  condyles  of  the  humerus.     Same  as  figure  253. 


Fig.  27.? — The  rlcfoririily  seen  ;iflir  .1  supr.K  ondyloifl  fraclurt  of  the  humerus.     Note  that  the  nor- 
mal bony  relations  i>i  the  olecranon  arc  undisturbed  (after  Pedro  Chulro,  Buenos  Aires). 


245 


246 


FRACTURES    OF    THE    HUMERUS 


factory  for  this  purpose  (see  Fig.  293).  The  maximum  swelling 
will  have  taken  place  after  forty-eight  to  seventy-two  hours. 
This  temporary  dressing  will  rarely  be  needed.     In  general,  it 


ifig.  274. — Supracondyloid  fracture  of 
humerus.  Elbow  flexed  to  a  right  angle. 
Diagram  to  show  displacement  of  bones. 


Fig.  275. — Dislocation  of  both  bones  of 
the  forearm  backward.  Elbow  flexed  to 
right  angle.  Diagram  showing  relative 
position  of  bones.  Compare  with  figure 
274. 


Humeral  shaft. 


Epiphysis. 

Capilellum. 


Fig.  276. — Displacement   of    lower   epiphysis  of    humerus   backward,   with   fracture  of    the 
diaphysis.     Child  seven  years  of  age  (X-ray  tracing). 


may  be  stated  that  the  arm  should  be  placed  in  that  position  in 
which  it  is  found,  upon  experiment  with  the  fracture  under  con- 
sideration, that  the  fragments  are  best  held  reduced. 


Fig.  2M1. 
Figs.  277-281. — Separation  of  the  lower   humeral  epiphysis.     Illustrating  varying  degrees  of  dis- 

phicement. 

247 


Fig.  2S2. — Separation  of  lower  humeral  epiphysis. 


Fig.  283. — Same  as  Fig.  282.  An  attempt  to  approximate  the  fragments  has  been  made  under 
an  anesthetic.  Note  the  lower  end  of  the  upper  fragment  in  the  bend  of  the  elbow  ready  to  impede 
motion. 

248 


Treatment  of  fractures  of  the  elbow 


249 


Fractures  of  the  internal  epicondyle,  of  the  internal  condyle,  of 
the  external  condyle  and  T-fractures  into  the  joint  are  best  treated, 
as  a  rule,  in  the  acutely  flexed  position. 

Experimental  evidence,  both  upon  the  cadaver  and  on  the 
anesthetized  living  subject,  confirmed  by  clinical  experience 
extending  over  a  number  of  years  in  the  hospital  and  private 
practice    of    many    different    surgeons,    demonstrates    that    the 


Olecranon  fossa.  . 

Internal  portion  of 

epiphysis. 


Ulna 


Humeral  epiphysis  and 

.      bits  from  the  diaphy- 

sis. 
'  Capitellum. 
—  -  Radial  epiphysis. 

-  — ■  Radius. 


Fig.  284. — Separation  of  the  lower  epiphysis  of  the  humerus,  after  union.  Anteroposterior 
view.  This  figure  illustrates  the  fact  that  the  epiphysis  does  not  include  the  condyles  of  the 
humerus  (X-ray  tracing). 

acutely  flexed  position  (Jones')  actively  reduces  and  holds  reduced 
the  fractures  previously  mentioned.  In  the  acutely  flexed  position 
the  coronoid  process  in  front,  the  trochlear  surface  of  the  olec- 
ranon behind,  and  the  fasciae  posteriorly  and  laterally,  together 
with  the  tendon  of  the  triceps  posteriorly,  hold  the  fragments 
reduced  and  close  to  the  shaft  of  the  humerus. 

Method  of  Using  the  Acutely  Flexed  Position:  The  condyles 
of  the  humerus  are  grasped  by  the  thumb  and  finger  of  one  hand, 
a  finger  of  the  other  hand  is  placed  in  the  bend  of  the  elbow, 
traction  is  made  upon  the  forearm,  and  it  is  slowly  flexed  to  an 
acute  angle.  While  the  forearm  is  being  flexed,  traction  and 
lateral  pressure  are   brought   to  bear  upon  the  loose  fragments 


A  i;  C 

Fig.  285. — A,  T-fracture  into  joint,      b,  c.  Fracture  into  joint  with  displacement  of  humeral  fragment. 


Fig.  286. — T-fracture  of  the  lower  end  of  the  humerus. 


Fig.  287. — T-fracture  of  lower  end  of  humerus. 
250 


Fig.  288. — An  injury  to  the  humeral  lower  epiphy- 
sis on  radial  side. 


Fig.  28g. — 'A  fracture  of  the  neck 
of  the  radius  and  a  starting  of  the 
external  part  of  the  lower  humeral 
epiphysis.  The  capitellum  is  dis- 
placed upward  slightly. 


Fig.  290. — A  T-fracture  into  the  elbow-joint. 


V/i, 


•U&MK 


^uali**4u. 


FIk-  291. — A  .separation  and  a  dis- 
placement backward  of  the  lower 
epiphysis  of  the  humerus. 


251 


Fig.  202. — A  separation  ami  displacement 
inward  of  the  lower  epiphysis  of  the  hu- 
merus. 


252 


FRACTURES    OF    THE    HUMERUS 


of  the  humerus  to  correct  existing  malpositions.     These  manip- 
ulations will  materially  assist  in  the  reduction  (see  Fig.  294). 

The  degree  of  flexion  will  be  determined  by  the  obstruction 
offered  by  the  local  swelling.  If  the  swelling  is  great,  or  is  likely 
to  increase  very  much,  then  the  degree  of  flexion  must  be  less 
than  when  there  is  no  swelling.  In  the  bend  of  the  elbow,  to 
prevent  chafing,  is  placed  a  piece  of  gauze  upon  which  has  been 
dusted  a  dry  powder.  This  acutely  flexed  position  is  maintained 
by  an  adhesive-plaster  strap,  three  inches  wide,  passing  about 
the  arm  and  forearm  (see  Fig.  295).  This  strap  should  be  placed 
upon  the  upper  arm  as  high  as  the  axillary  fold,  and  upon  the 
forearm  just  above  the  styloid  of  the  ulna.  A  piece  of  linen  or 
compress  cloth  (cotton  cloth)  is  placed  under  the  forearm  and 
hand  where  they  would  come  in  contact  with  the  skin  of  the 


Fig.  293. — Patterns  of  pieces  used  in  making  the  usual  (soldered)  internal  right-angle  splint, 
seen  applied  in  figure  304. 

chest.  This  should  be  pinned  so  as  not  to  slip  from  position.  The 
arm  thus  flexed  is  supported  by  a  swathe  sling  (see  Fig.  296) 
made  of  cotton  cloth,  fifteen  inches  wide,  folded  three  times,  and 
long  enough  to  extend  twice  around  the  body.  This  is  applied 
as  illustrated  (see  Figs.  297,  298,  299).  The  elbow  is  held  to  the 
side  by  pinning  a  strip  of  compress  to  the  swathe  at  the  elbow 
and  posteriorly  (see  Fig.  298). 

Precautions  in  Using  the  Acutely  Flexed  Position:  The  arm 
is  inspected  each  day  for  the  first  week.  It  is  necessary  to  note 
whether  with  the  increase  in  the  swelling  the  flexion  of  the  arm 
should  be  diminished,  and  whether  with  diminution  in  the  swell- 
ing  flexion   may    be   increased    with    safety.     The   radial   pulse 


TREATMENT   OF    FRACTURES    OF   THE    ELBOW 


253 


should  be  diminished,  and  whether  with  diminution  in  the  swell- 
ing flexion  may  be  increased  with  safety.  The  radial  pulse 
should  be  felt  as  the  flexion  is  diminished,  so  as  to  avoid  com- 
pression of  the  vessels  at  the  bend  of  the  elbow.  There  should 
be  no  pain  associated  with  this  acutely  flexed  position.  A 
certain  amount  of  discomfort  may  be  complained  of.  Real 
pain  will  be  indicative  of  too  great  pressure,  and  if  it  is  present, 
the  forearm  should  be  less  acutely  flexed.  Chafing  should  be 
looked  for  at  the  bend  of  the  elbow,  under  the  forearm  and  hand 


Fig.  294. — Supracondyloid  fracture  of  the  humerus.  Method  of  reduction  before  applying 
retentive  splint.  Countertraction  on  upper  arm.  Traction  on  condyles  of  humerus  with  right 
hand  ;  backward  pressure  with  thumb  of  left  hand.  Also  illustrative  of  method  of  beginning 
acute  flexion. 

and  on  the  chest,  where,  if  necessary,  fresh  powder  and  com- 
press cloth  should  be  placed.  The  edge  of  the  adhesive  plaster 
may  cause  chafing  of  the  skin  upon  the  posterior  surface  of  the 
forearm  and  upper  arm.  It  may  be  necessary  to  place  beneath 
the  plaster  small,  carefully  folded  compresses  of  cotton  cloth  to 
protect  the  skin  (see  Fig.  297). 

Later,  in  changing  the  adhesive  plaster,  the  skin  may  be  washed 
with  alcohol  and  then  with  soap  and  water,  to  the  great  comfort 
of  the  patient.  The  alcohol  removes  all  adhesive  plaster  sticking 
to  the  skin.  If  the  adhesive  plaster  chafes  the  skin,  as  it  so 
often  does  in  children,  it  will  be  necessary  to  place  a  bit  of  gauze 
under  the  adhesive-plaster  strips,  leaving  enough  of  the  sticky 


254 


FRACTURES    OF   THE    HUMERUS 


side  of  the  plaster  uncovered  to  catch  the  skin  and  thus  keep 
it  from  slipping  entirely  loose.  The  carrying  angle  of  the  arm 
will  be  preserved  if  the  fragments  are  approximateh^  reduced; 
it  cannot  be  maintained  otherwise.  The  acutely  flexed  position 
reduces  the  fragments  in  the  fractures  under  consideration ;  there- 
fore it  will  preserve  the  carrying  angle. 


Fig.  295. — Position  of  flexion.  Note 
broad  adhesive  strap,  protected  poste- 
riorly to  prevent  cutting.  The  cravat 
sling  to  be  applied  over  this. 


Fig.  296. — Left  elbow  in  position  of  forced  flexion. 
Gauze  in  bend  of  elbow.  Thin  axillary  pad.  Pad 
■  under  hand  and  wrist.  Gauze  protection  under  fore- 
arm, held  by  safety-pin  from  slipping.  Adhesive 
plaster  maintaining  flexion.  Skin  protected  on  upper 
arm  by  gauze  compress  from  cutting  of  adhesive 
plaster. 


Transverse  Fracture  of  the  Shaft  Above  the  Condyles. — There  is 
usually  an  overlapping  of  the  fragments.  This  is  evident  in 
the  backward  displacement  of  the  lower  fragment  and  forearm 
and  in  the  forward  displacement  of  the  upper  fragment  (see 
Fig-  315)- 

It  will  be  necessary  in  order  to  effect  reduction  of  this  fracture 


tre;atment  of  fractures  of  the  elbow 


255 


to  make,  with  the  aid  of  an  assistant,  hyperextension  of  the  elbow, 
counter  traction  and  pressure  backward  upon  the  upper  fragment 
while  traction  and  a  forward  pull  are  made  upon  the  lower  frag- 
ment by  grasping  the  arm  above  the  condyles  (see  Fig.  294). 
The  periosteal  separation  from  the  shaft  of  the  humerus  is  the 
hinge  on  which  the  distal  small  fragment  hangs  (Thomas).  The 
internal  right  angle  splint  at  first,  while  there  is  considerable 


tig.  297.— Applying    figure-of-eight    cravat   to    flexed   elbow 
(after  Lund). 


Fin.  2i)t>. — Strap  from 
elbow  to  cravat  to  prevent 
abduction  of  flexed  elbow- 


swelling  of  the  elbow  region,  best  holds  this  fracture,  for  it  exerts 
continuous  pressure  backward  upon  the  upper  fragment  and  pre- 
vents displacement  (see  Figs.  301,  302).  It  is  padded'with  sheet 
wadding  and  applied  as  illustrated.  Two  straps  are  needed  upon 
the  forearm  to  hold  this  splint  in  pood  position  (see  Figs.  303,  304). 
The  strap  at  the  wrist  should  be  so  apphed  that  there  is  no  pres- 
sure  upon    the    styloid    process    of   the    ulna.       Long-continued 


256 


FRACTURES   OF    THE)    HUMERUS 


pressure  upon  this  bony  process  would  cause  a  pressure  sore. 
In  applying  the  adhesive  plaster  it  is  wise  to  apply  it  so  loosely 
that  there  is  no  undue  pressure  upon  the  arm,  which  might 
retard  the  circulation.  The  arm  is  then  covered  with  a  roller 
bandage  of  sheet  wadding,  over  which  is  placed  a  roller  bandage 
of  cheese-cloth.     This   should   be   applied   smoothly   and  firmly 


Fig.  299. — Fastening  figure-of-eight  cravat  over  folded 
compression  on  opposite  side  of  chest.  Elbow  region  open  to 
inspection. 


Fig.  300. — Adhesive 
plaster  strip  showing 
bits  of  gauze  arranged 
so  as  to  protect  skin 
from  plaster  without 
impairing  efficiency  of 
the  plaster. 


from  the  hand  to  the  upper  end  of  the  splint.  As  the  swelling 
about  the  elbow  begins  to  subside,  pads  of  cotton  cloth  (com- 
press cloth)  may  be  placed  at  each  side  of  the  olecranon  below 
each  condyle.  The  pressure  of  a  frequently  renewed  bandage 
on  these  pads  will  hasten  the  disappearance  of  the  swelling. 
It  is  important  to  avoid   the   forward  and  backward  deformity 


TREATMENT    OF    FRACTURES    OF   THE    ELBOW 


257 


in  treating  this  fracture  (see  Figs.  305,  306,  307).  Sometimes  it 
may  be  possible,  without  causing  too  great  tension  at  the  elbow 
from  the  swelHng,  to  place  the  elbow  in  a  position  of  acute  flexion 
instead  of  at  a  right  angle.  Thus  would  be  assured  in  certain  types 
of  this  fracture  a  more  positive  hold  on  the  lower  fragment.  Even 
if  the  acute  flexion  is  impossible  at  first,  later  it  may  more  safely  be 
employed. 

Dislocation  of  Both  Bones  of  the  Forearm  Backward. — If  there 


Fig.  301.  Fracture  of  the  elbow.  Application  of  the  internal  right-angle  splint.  First 
strap  already  applied.  Manner  of  holding  splint  and  arm  as  the  forearm  is  flexed  up  to  the 
splint  (see  Fig.  302). 


is  no  tendency  to  displacement  after  reduction  is  accomplished, 
the  right-angle  position  with  internal  splint  is  the  best  treat- 
ment. If,  on  the  other  hand,  there  is  a  tendency  to  displace- 
ment, the  acutely  flexed  position  will  be  the  best  for  the  arm 
because  in  case  the  coronoid  process  is  broken  it  will  insure 
its  close  approximation  to  the  ulna. 

Separation  of  the  lower  epiphysis  of  the  humerus  will  be  best 
treated  in  the  right-angle  position,  the  same  as  a  fracture  of  the 
humerus  above  the  condyles  (see  Figs.  277-281,  308). 
17 


258 


FRACTURES   OF   THE   HUMERUS 


Fracture  of  the  neck  of  the  radius  is  best  treated  by  the  internal 
right-angle  splint. 

Fracture  of  the  olecranon  is  discussed  elsewhere. 


Fig.  302  —  Fracture  of  the  elbow.    Application  of  the  internal  angular  splint.    Placing  second 
strap.    The  angle  of  the  splint  is  crowded  into  the  bend  of  the  elbow  (see  Fig,  301). 


Jf 

fH 

^ 

il          "'^^^p^i^ 

\ 

A 

Fig-  303. — Two  straps  insufficient  to  hold        Fig.  304. — -Third   strap  is  necessary  to  hold 
iw  in  intprnol  rio-Vit.or,rrio  or^iivit      Q,^i;r,f  the  Splint  close  to  the  flexed  elbow. 


^ig-  303. — two  Straps  insufficient  to  hold 
elbow  in  internal  right-angle  splint.  Splint 
has  slipped  away  from  the  bend  of  the  elbow 


The  After-care  of  Injuries  to  the  Elbow. — The  reapplying 
of  splints  and  of  apparatus  should  be  done  often  enough  to  be 


THE    AFTER-CARE    O^    INJURIES    TO    THE    ELBOW 


259 


sure  that  they  are  efficient,  and  that  there  is  no  undue  swelhng 
of  the  arm  and  hand  or  pressure  upon  the  arm.  Rebandaging  the 
hand  and  the  arm  each  day,  if  the  internal  angular  splint  is  used, 
is  important.  All  apparatus  should  be  removed  at  least  once  a 
week,  and  carefully  inspected  twice  during  this  interval.     Passive 


Fig.  305. — Supracondyloid  fracture. 
Obliquity  of  the  lime  of  fracture  from  be- 
hind downward  and  forward.  Diagram 
showing  deformity  with  elbow  flexed  and 
little  sliding  of  fragments. 


Fig.  306. — ^Supracondyloid  fracture. 
Obliquity  of  the  line  of  fracture  from  above 
downward  and  backward .  Diagram  show- 
ing tendency  to  posterior  deformity  if  acute 
flexion  of  forearm  is  attempted. 


Fig.  307. — Supracondyloid  fracture  with  slight  anterior  displacement,  wired.  Recovery, 
with  slight  anterior  bending  of  fragments.  Wire  seen  in  situ  (X-ray  tracing.  Massachusetts 
General  Hospital,  1077). 

motion  should  be  instituted  late  rather  than  early.  In  most 
instances  it  will  be  wise  to  delay  passive  motion  until  union  is  firm 
— from  the  third  to  the  fourth  week.  It  should  be  of  the  gentlest 
sort;  passive  motion  that  is  painful  does  harm. 

Massage  to  the  hand,  wrist,  forearm,  elbow,  and  upper  arm, 


26o 


FRACTURES    OF    THE    HUMERUS 


after  the  primary  swelling  has  begun  to  subside,  is  of  great  value. 
It  should  be  given  at  first  without  disturbing  the  apparatus' 
and  the  retentive  adhesive  plaster.  Given  every  day  or  every 
other  day,  it  will  accomplish  considerable  in  maintaining  the  integ- 
rity of  the  muscles  of  the  part.  The  employment  of  a  professional 
masseuse  is  not  always  necessary.  The  physician  should  give 
the  massage  or  instruct  a  competent  person  how  to  give  it. 

Omission  of  Splint  or  Retentive  Apparatus:  This  should  be 
tentative  and  gradual  after  union  is  known  to  be  firm — in  the  fifth 


Fig.  30S  — Separation  and  backward  displacement  of  lower  epiphysis   of  humerus.     Note 
stripping  of  periosteum  off  posterior  surface  of  shaft.    Right-angled  splint. 


or  sixth  week.  The  arm  should  be  allowed  to  rest  in  a  sling  with- 
out the  splint  for  a  few  hours  and  then  the  splint  applied.  The 
following  day  a  longer  interval  is  granted  without  the.  splint. 
Gradually,  the  splint  is  removed  entirely.  A  snugly  fitting 
bandage  will  often  prove  comfortable  as  a  support  on  first  leaving 
off  the  splint.  Passive  motion,  massage,  and  active  use  of  the 
arm  will  now  assist  in  regaining  the  use  of  the  joint.  At  this 
stage  the  carrying  of  dumb-bells,  pails  or  baskets  filled  with 
sand,  and  the  doing  of  certain  gymnastic  movements  with  the 


THE    AFTER-CARE    OF    INJURIES   TO    THE    ELBOW 


261 


Fig.  3°9- — Flexion  fracture,  lower  end  of  humerus. 


Fig.  310. — Extension  fracture  of  humerus. 
Note  bad  position  of  lower  end. 


Fig.  311. —  Extension  fracture, 
stripped-up  periosteum. 


Fig.  312. — ^Extension  fracture.     Note  stripping  of 
periosteum  from  posterior  part  of  humerus. 


Fig.  513. — Separation  of  lower  hu- 
meral epiphysis.     Projection. 


Fig.  314- — Fracture  of  lower  end  of  humerus.   Anterior 
Ijrojcction  of  upper  fragment; 


262 


FRACTURES    OF   THE    HUMERUS 


injured  arm  will  be  of  material  aid.     All  violent  exercise  of  the 
part  is  to  be  avoided.     That  amount  of  exercise  may  be  allowed 


Fig.  315.^-Separation  of  the  lower  humeral  epiphysis  with  fracture  of  the  shaft.  Displacement 
of  the  forearm  backward  and  of  humeral  shaft  forward.  It  is  often  impossible  to  reduce  this  fracture 
without  incision.     Note  the  posterior  periosteal  separation  in  the  shaft  of  the  humerus. 


Fig.  316. — Separation  of  the  lower  humeral  epiphysis.     Before  operation.     Note  the  forward 
projection  of  the  lower  end  of  the  fragment  of  the  humerus  impeding  flexion. 


that  leaves  the  arm  moderately  tired.      A  fatigue    that  is  not 
recovered  from  within  a  half-hour's  rest  is  excessive. 


THE  PROGNOSIS  OF  FRACTURES  OF  THE  ELBOW 


263 


L.  .  .  .  .  -, 

Fig.  317. — Separation  of  the  lower  humeral  epiphysis.  After  operation.  Note  the  normal 
angle  of  flexion.  Over  one  year  following  the  open  incision  and  reduction,  functions  and  movements 
of  elbow  and  forearm  are  normal.    Same  case  as  in  Fig.  316. 


Fig.  318. — Supracondyloid  fracture  of  the  humerus.  Note  the  inability  to  extend  the  fingers 
or  completely  flex  which  might  follow  too  prolonged  immobilization  and  absence  of  early  massage 
and  passive  motion.     Injury  to  the  median  nerve  (after  Pedro  Chutro,  Buenos  Aires). 


The   Prognosis. — Up  to  the  time  of  the  present  introduction 
of  the  acutely  flexed  position  in  the  treatment  of  fractures  at 


Fig.  319. — Injury  to  the  elbow-joint.      AppLar.inLcs  fi41o\\inK  fracture  of  the  external    condyle  of 
the  humerus  (after  Pedro  Chutro,  Buenos  Aires). 


Fig.  320. — Supracondylar  fracture  of  the  humeral  shaft.     Note  the  deformity  at  and  above  the  elbow 
(after  Pedro  Chutro,  Buenos  Aires). 
264 


THE    PROGNOSIS    OF    FRACTURES    OF    THE    ELBOW 


265 


the  elbow,  the  movement  most  easily  lost  and  with  greatest  dif- 
ficulty regained  was  that  of  flexion.  By  the  use  of  the  acutely 
flexed  position  in  suitable  cases  the  prognosis  has  improved 
remarkably  in  this  respect.  Now  all  of  flexion  is  ordinarily 
preserved,  and  the  more  easily  acquired  extension  is  obtained 
as  usual,  so  that  the  prognosis  as  to  motion  in  these  cases  is 
good.  Although  anatomically  perfect  results  are  not  always 
obtained,  most  fractures  of  this  region  recover  with  a  useful  arm. 


Fig.  321. — Injury  to  the  elbow-joint :  appearances  following  T-fracture  of  the  lower  end  of  the  humerus. 
Displacement  of  ulna  inward  (after  Pedro  Chutro,  Buenos  Aires). 


These  fractures  of  the  elbow  region  should  be  kept  under  obser- 
vation for  at  least  four  months.  It  is  wise  to  treat  such  cases 
until  all  that  can  be  achieved  toward  a  restoration  of  function 
has  been  accomplished. 

At  the  time  of  the  first  examination  of  the  elbow  the  nature 
of  the  injury  and  its  seriousness  should  be  explained  carefully 
to  the  patient  or  his  friends.  A  guarded  outlook  should  be  ex- 
pressed, particularly  with  reference  to  the  function  of  the  joint. 
vSome  limitation  of  motion  may  exist  after  all  that  is  possible 


266 


FRACTURES    OF    THE    HUMERUS 


has  been  done  (see  Fig.  322).  How  much  limitation  of  motion 
will  exist  it  is  impossible  to  state.  There  may  be  none  what- 
ever. The  patient  and  his  friends  should  be  encouraged  with 
the  statement  that  just  as  great  usefulness  of  the  elbow-joint 
will  be  obtained  as  is  consistent  with  the  character  of  the  injury. 
The  importance  of  the  injury  demands  of  every  physician  a 
painstaking  anatomical  examination  with  the  aid  of  an  anesthetic, 


Fig.  322. — Volkmann's  contracture.  Illustrating  the  evil  result  following  too  great  compression 
of  the  forearm  by  ordinary  wooden  splints.  Note  cicatrix  below  elbow  on  the  anterior  surface  of  the 
forearm.  Note  permanent  deformity  of  hand  due  to  involvement  of  muscles  and  nerves  in  degenera- 
tive changes  from  pressure. 


careful  attention  to  minute  details  in  the  initial  treatment,  and 
intelligent  solicitude  in  the  after-care  of  all  traumatisms  to  the 
elbow-joint. 

Volkmann-Leser  Contracture. — A  complication  of  elbow- 
joint  and  forearm  fractures.  By  Volkmann's  contracture  is  under- 
stood a  contraction  or  flexion  of  the  fingers  and  wrist,  which  ap- 
pears rapidly,  with  loss  of  power  in  the  muscles  of  the  forearm, 


VOIvKMANN'S    CONTRACTURE  267 

usually  following  injury  to  the  region  of  the  elbow  or  forearm  in 
young  children  (Dudgeon) . 

This  contracture  is  a  serious  matter,  if  recognized  it  can  be 


Fig,  323. Case  i  in  Mr.  Dudgeon's  series  showing  characteristic  deformity  of  Volkmann's  con- 
tracture. The  original  injury  was  on  December,  1896.  This  photograph  was  taken  November,  1901, 
five  years  later.     No  treatment.     Note  final  bad  result. 

remedied,  if  misunderstood  a  late  attempt  at  relief  is  often  un- 
availing.    It  occurs  far  more  commonly  than  is  generally  sup- 


Fig.  324. — r.  Volkmann's  contracture  following  fracture  of  the  lower  third  of  humerus.  Child 
12  years  old.  Operation  10  weeks  after  the  accident,  by  tendon-lengthening,  restored  motion  after 
one  year  almost  normally  in  elbow,  forearm,  wrist,  and  fingers,  but  not  as  strong  as  formerly.  Arm 
before  operation  in  case  2.  r.  Transverse  scar  three  inches  long  running  half-way  around  the  arm 
three  inches  above  the  elbow-joint  ;  2,  atrophy  of  flexor  bellies  ;  3,  flexion  and  fixation  of  wrist ;  4, 
extension  and  fixation  of  proximal  phalanges  ;  5,  acute  flexion  and  fixation  of  two  distal  segments  of 
phalanges  (case  of  Ferguson,  Chicago). 

posed.  I  have  seen  several  cases  during  the  past  few  years. 
The  cause  of  the  contracture  is  probably  an  ischaemic  necrosis  of 
the  muscles  dependent  upon  too  great  pressure  upon  the  soft 


268 


FRACTURES    OF   THE    HUMERUS 


parts.  The  vascular  supply  is  interfered  with  and  the  muscles 
die,  leaving  a  cicatricial-like  tissue  in  their  place — an  ischemic 
necrosis.  Cases  of  Yolkmann's  contracture  occur  when  no  splint 
has  been  used  and  following  thrombosis  of  vessels. 

This  contracture  is  seen  in  the  arms  of  children,  largely,  who  have 
fractured  the  lower  end  of  the  humerus,  elbow,  or  forearm.  The 
splint  is  applied  too  tightly.  No  allowance  is  made  for  the  usual  sub- 
sequent swelling.  The  splints  are  not  removed  and  the  part  is  not 
inspected,  as  is  wise,  each  day  or  two.  The  damage  may  be  done 
in  two  or  three  days.  Upon  discovering  the  condition  the  fingers 
are  dusky  in  color,  and  swollen.    There  is  rarely  any  pain.     Upon 


Fig.  325. — \'olkmann's  contracture.  Note  disappearance  of  flexion  of  lingers  in  wrist  flexion. 
This  case  was  operated  by  Littlewood  by  tendon-lengthening  with  satisfactory  functional  result  (case 
of  Mr.  Littlewood,  Leeds). 


the  forearm  usually  will  be  found  a  slough  or  a  pressure  sore 
apparently  extending  only  through  the  skin.  The  importance  of 
frequently  inspecting  the  part  fractured  and  the  extremity  in- 
volved is  illustrated  in  Fig.  322.  This  child  received  an  injury 
to  the  upper  extremity  (the  details  are  unessential) ;  the  arm  was 
immobilized  securely  by  wooden  splints.  Instead  of  regularly, 
at  short  intervals,  inspecting  the  arm  to  be  sure  that  it  was  all 
right,  the  splints  were  left  on  many  days.  The  result  of  continu- 
ous pressure  upon  the  soft  parts  is  seen  in  the  permanent  deformity 
present.     The  position  of  the  fingers  is  characteristic — viz.,  the 


volkmann's  contracture;  .269 

wrist  is  extended,  the  metacarpophalangeal  joints  are  extended, 
the  interphalangeal  finger-joints  are  flexed.  Upon  flexing  the 
wrist  the  fingers  can  be  extended.  The  hand  is  pronated  and  the 
forearm  is  semi-flexed.  Supination  and  pronation  of  the  forearm 
are  impossible.  The  flexor  group  of  muscles  of  the  forearm 
is  much  wasted.  There  is  a  thickening  of  the  forearm  at  the 
place  corresponding  to  the  base  of  the  ulcer.  Sensation  in  these 
cases  is  usually  normal.  The  electrical  reactions  are  normal. 
The   hand   feels   cold   and   appears  blue.     The   skin   is   smooth. 


Fig.  326. — Volkmann's   contxacture.       Note   flexion   in    wrist  extension    (case   of    Mr.    Littlewood, 

Leeds). 

The  bones,  in  cases  of  long  duration,  are  undeveloped,  as  in  infan- 
tile paralysis. 

Ivittlewood  has  emphasized  the  fact  that  a  splint  improperly 
applied  is  not  the  sole  cause  of  the  condition,  for  the  contracture 
has  followed  where  no  splint  has  been  worn.  Tremendous  swell- 
ing of  the  soft  parts  may  cause  local  pressure  upon  the  circula- 
tion. The  contracture  has  followed  after  the  main  artery  of  a 
limb  has  been  ruptured  and  also  after  prolonged  exposure  to  severe 
cold.  So  that  the  etiology  is  well  expressed  thus:  The  contrac- 
ture is  a  result  of  prolonged  interference  with  the  normal  circula- 
tion. 

A  case  of  Volkmann's  contracture  usually  gives  the  story  of 
an  injury  to  the  elbow  or  forearm  associated  with  a  tremendous 


270 


FRACTURES    OF    THE    HUMERUS 


swelling  of  the  soft  parts.  Splints  have  been  applied.  The 
paralysis  and  contracture  appear  at  about  the  same  time,  syn- 
chronously. In  paralysis  from  nerve  origin  contracture  comes 
later  and  gradually  increases. 

Peripheral  nerve  paralyses  must  be  differentiated  from  Volk- 
mann's  contracture.  The  history  and  electrical  reactions  will 
clear  these  up;  of  course,  a  peripheral  nerve  may  be  involved 
secondarily  in  Volkmann's  contracture.  This  fact  must  not  be 
lost  sight  of. 

Disturbances  of  sensation  appear  in  certain  cases  of  Volkmann's 
paralysis  due  to  the  pressure  upon  one  or  more  of  the  nerves  of 


Fig.  327. — \'olkmann's  contracture  following  an  injury  to  the  elbow  and  treatment  by  splints.     Note 
scar  in  upper  third  of  the  palmar  surface  of  the  left  forearm.     Note  attitude  of  hand  and  fingers. 


the  forearm,  usually  the  ulnar,  sometimes  the  median  and  radial, 
and,  unfortunately,  sometimes  all  three.  This  pressure  upon  the 
nerve  is  caused  by  the  cicatrix  of  the  damaged  part.  The  exact 
area  of  disturbed  sensation  will  depend  upon  the  precise  nerve  or 
nerves  involved.  Atrophy  of  the  muscles  supplied  by  the  in- 
volved nerve  will  be  evident. 

The  contracture  following  anterior  poliomyelitis  and  Little's 
disease  should  be  borne  in  mind  and  not  confounded  with  Volk- 
mann's contracture. 


volkmann's  contracture;       -  271 

Treatment. — When  a  case  of  Volkmann's  contracture  presents 
itself  for  treatment,  two  questions  must  always  be  answered. 
Are  the  nerve  trunks  involved  in  the  cicatrix?  Can  the  contrac- 
tures as  such  be  relieved  ?  A  freeing  of  the  nerves  will  often  effect 
great  improvement.  The  severity  of  the  particular  case  and  the 
special  features  present  will  determine  the  exact  procedure  to  be  em- 
ployed. If  a  case  is  seen  immediately  after  the  injury  (i.  e.,  within 
a  week  or  two)  it  may  be  that  massage  and  stretching  of  the  muscles 
of  the  forearm  regularly  and  continuously  every  day  (at  least  twice 
daily)  for  a  year  or  two,  will  give  a  satisfactory  result.  Cases  are 
recorded  in  which  this  is  the  result  (Dudgeon).  The  stretching 
is  best  done  without  an  anesthetic.  If  done  under  anesthesia  the 
stiffness  is  apt  to  become  greater  than  before  treatment. 

If  the  case  is  seen  when  the  contracture  is  established,  opera- 
tive measures  alone  will  be  of  assistance.  The  contracture 
usually  increases  for  two  or  three  months  before  reaching  its 
maximum.  Operative  treatment  had  better  be  delayed  until 
this  maximum  contraction  is  established. 

Four  operative  procedures  are  to  be  considered :  i .  A  lengthen- 
ing of  the  flexor  tendons  of  the  forearm  (Littlewood  and  David- 
sohn,  1 891).  The  exact  amount  of  lengthening  of  the  tendons  is 
determined  by  the  ability  fully  to  extend  the  fingers  with  the  wrist 
in  the  extended  position.  2.  A  shortening  of  the  radius  and  ulna 
(Garre,  1895),  to  compensate  for  the  contraction  of  the  muscles. 
3.  A  myotomy  of  the  muscles  (Bradford,  1901)  has  been  success- 
fully done.  4.  A  dissection  of  the  nerves  (Hay ward  Cushing,  1904) 
free  from  the  cicatrix  will  often  restore  nerve  function.  It  may 
be  impossible  to  improve  the  contracture  by  any  other  means 
than  freeing  the  nerve  and  then  stretching  the  contracted  parts. 

After  operative  treatment  it  is  very  necessary  to  continue  active 
and  passive  movements,  massage,  and  faradic  stimulation  of  mus- 
cles for  many  months  to  increase  the  functional  usefulness  com- 
mensurate with  the  increased  range  of  passive  motion  secured  by 
operation. 

The  results  following  operation  have  been  pretty  satisfactory. 
Without  treatment  of  any  kind  the  condition  is  most  deplorable. 


272 


FRACTURES    OF    THE    HUMERUS 


A  SERIES  OF  UNSELECTED  CASES  OF  INJURY  TO  THE  LOWER 
END  OF   THE  HUMERUS,  ILLUSTRATING   THE  ANATOM- 
ICAL AND  FUNCTIONAL  RESULTS  FIVE  YEARS 
AFTER    THE    ACCIDENT. 

I  present  here,  briefly,  the  end  results  in  a  series  of  unselected 
cases  of  fractures  of  the  lower  end  of  the  humerus  occurring  in 
childhood.  The  final  observation  was  made,  in  each  instance, 
five  years  after  the  receipt  of  the  injury.     The  original  diagno- 


Ulna. 


Radius. 


Fig.  32S. — X-ray.  Anteroposterior  view  of  the  uninjured  elbow-joint  of  a  child  fourteen 
years  old.  The  forearm  is  completely  extended.  This  X-ray  is  shown  for  comparison  with 
those  X-rays  that  follow.    This  figure  to  be  used  as  a  standard  of  comparison. 


sis  was  made  without  the  assistance  of  the  X-ray.     The  X-rays 
here  presented  demonstrate  the  existing  bony  relations. 

The  treatment  of  these  cases  varied  slightly.  The  child  was 
etherized,  the  elbow  thoroughly  examined,  and  the  forearm 
placed  in  the  position  which  seemed  to  hold  the  fracture  most 
completely  reduced;  either  the  acutely  flexed  position  or  that 
at  a  right  angle  was  the  position  chosen  in  which  to  retain  the 


INJURIES    TO    THE    IvOWER    END    OF    THE    HUMERUS         273 

elbow.  Massage  was  used  immediately,  and  at  frequent  inter- 
vals, with  primary  immobilization,  without  the  removal  of  the 
fixation  dressing.  The  elbow  was  kept  immobilized  for  from 
four  to  seven  weeks.  At  the  end  of  that  time  passive  motion 
was  employed  and  active  motion  encouraged  up  to  the  point  of 
just  not  hurting  the  child.  Any  manifestation  of  pain  during 
passive  motion, was  immediately  respected. 

The  X-rays  in  each  case  are  here  presented,  showing  the  rela- 
tive position  of  the  elbow-joint  bones,  and  especially  the  condi- 


Radius 


Fig.  329. — ^X-ray.  Lateral  view  of  the  elbow-joint  seen  in  figure  32S.  The  epiphyseal 
line  separating  the  olecranon  process  is  distinctly  shown.  The  forearm  is  somewhat  flexed. 
This  figure  to  be  used  as  a  standard  of  comparison. 


tion  of  the  lower  end  of  the  humerus,  five  full  years,  in  every 
instance,  after  the  fracture.  In  each  case  the  functional  results 
are  perfect.  The  anatomical  results  are  seen  upon  inspection 
of  the  X-ray. 

Although   the  anatomic  conditions   are   not   perfect  in  these 
cases   by  any  means,  the  functional  results  are  most  satisfac- 
tory.     With  one  or  two  exceptions  there  is  no  noticeable  de- 
formity upon  inspection  of  the  elbow  once  injured. 
18 


Radius. 


Humerus. 


Fig-  330- — X-ray.  Anteroposterior  view  of  the  extended  elbow  of  a  boy  fourteen  j-ears 
old.  When  nine  years  old,  fracture  of  internal  condyle.  Five  years  after  the  fracture,  flexion 
of  the  elbow  is  possible,  fifteen  degrees  from  a  right  angle  ;  extension  is  limited  ten  degrees 
at  the  extreme  point ;  pronation  and  supination  are  normal.  The  carrying  angle  is  absent. 
Note  displacement  upward  of  internal  condyle  and  broadening  of  lower  end  of  humerus. 
Treatment,  acute  flexion. 


Humerus 


Radius. 


Ulna. 


Fig.  331. — Same  case  as  figure  330.     The  elbow  is  fle.xed. 
274 


Ulna. 


Radius. 


Fig.  332. — X-ray.  Anteroposterior  view  of  the  extended  elbow  of  a  boy  seventeen  years 
old.  Wlien  twelve  years  old  fracture  of  the  internal  epicondyle  and  a  dislocation  of  both  bones 
of  the  forearm  backward.  Five  years  after  the  fracture  and  dislocation,  flexion  is  possible 
seventeen  degrees  from  a  right  angle.  Extension  is  limited  eighteen  degrees.  Pronation  is 
very  slightly  limited.  Supination  is  normal.  The  carrying  angle  is  slightly  less  than  that  of 
the  well  arm.    Treatment,  right  angle  position. 


Ulna. 


Humerus. 


I'ig.  333-— The  same  as  figure  332.     The  elbow  is  flexed. 
27s 


Humerus. 


Radius. 


Fig-  334- — X-ray.  Anteroposterior  view  of  the  extended  elbow  of  a  boy  thirteen  years  old. 
When  eight  years  old,  fracture  of  the  external  condyle.  The  line  of  the  fracture  is  seen  in  the 
plate.  Five  years  after  the  fracture,  flexion,  pronation,  and  supination  are  normal.  Extension 
is  limited  seven  degrees.     The  carrying  angle  is  normal.     Treatment,  right  angle  position. 


Humerus. 


Ulna. 


Radius. 


Fig.  335-  X-ray.  Lateral  view  of  the  elbow-joint  of  a  boy  seventeen  years  old.  The 
arm  is  extended.  When  twelve  years  old,  fracture  of  the  external  condyle.  Five  years  after 
the  injury,  flexion,  extension,  pronation,  and  supination  are  each  normal.  The  carrying  angle 
is  normal.     Treatment,  acute  flexion. 

276 


Radius.  - 


Fig.  336- — X-ray.     Same  case  as  figure  335.    The  arm  is  extended,  but  the  view  is  an  antero- 
posterior one. 


Ulna. 


Humerus. 


Radius. 


Fig.  337- — X-ray.  Anteroposterior  view  of  the  elbow-joint  of  a  boy  eleven  years  old. 
The  arm  is  extended.  When  six  years  old,  received  a  T-fracture  of  the  lower  end  of  the  hu- 
merus into  the  elbow-joint.  The  widened  intercondyloid  space  is  apparent  in  the  X-ray  plate. 
Five  years  after  the  fracture,  flexion  is  possible  to  forty-eight  degrees,  just  beyond  a  right 
angle.  Extension  is  limited  thirty  degrees.  Pronation  and  supination  are  normal.  Treat- 
ment by  acute  flexion. 

277 


Radius. 


Ulna. 


Fig.  33S. — X-ray.  Anteroposterior  view  of  the  elbow-joint  of  a  girl  of  seven  years  of 
age.  The  arm  is  extended.  When  two  years  old,  received  a  T-fracture  of  the  lower  end  of 
the  humerus  into  the  joint.  Five  years  after  the  injury,  flexion,  extension,  pronation,  supi- 
nation were  all  normal.  The  carrying  angle  is  normal.  The  treatment  was  the  right  angle 
position. 


Humerus. 


Ulna. 


Fig.  339. — X-ray.     A  lateral  view  of  same  elbow  as  in  figure  338. 
278 


Ulna. 


Radius. 


Fig.  340. — X-ray.  Anteroposterior  view  ol  the  extended  elbow  of  a  boy  sixteen  years 
old.  When  eleven  years  old,  fractured  the  internal  condyle.  Five  years  after  the  fracture, 
flexion  is  nortnal,  extension  is  almost  normal  (see  X-ray  plate),  pronation  and  supination  are 
normal.  Carrying  angle,  about  normal.  Treatment  at  a  right  angle.  A  movable  internal 
condyle  can  be  felt. 


Radius, 


Ulna. 


Humerus. 


Fig.  341. — Same  case  as  figure  540.     The  elbow  is  fle.xed. 
279 


Capitellum 


Radial  epiphysis. 


Radius. 


Humerus. 


Ulna. 


Fig.  342. — X-ray.  Anteroposterior  view  of  the  extended  elbow  of  a  girl  seven  years  old. 
When  two  years  old,  fractured  the  external  condyle.  Five  years  after  the  fracture,  exten- 
tension,  flexion,  pronation,  and  supination  are  normal.  Carrying  angle  is  about  normal. 
Treatment  at  a  right  angle. 


t^^KKj^t 

Mjk 

Radius. 

Humerus. 

y 

L 

A 

Y 

Ulna. 

V        ^^^^I^^H 

Fig.  343. — Same  case  as  figure  342.     The  elbow  is  flexed. 
280 


Humerus. 


Capitellum. 

Radial  epiphysis. 

Ulna.  ""^Z^^^^Z^ 

Radius. 


Fig.  344. — X-ray.  Anteroposterior  view  ol  the  extended  elbow  of  a  boy  ten  years  old. 
When  five  years  old,  fractured  the  external  condyle.  Five  years  after  the  fracture,  flexion., 
pronation,  and  supination  are  normal.  Extension  is  slightly  limited.  The  carrying  angle  is 
normal.    Treatment  in  acute  flexion. 


Humerus. 


Radius. 


Ulna. 


FiK.  345-  X-ray.  Anteroposterior  view  of  the  extended  elbow  of  a  girl  twelve  years  old. 
When  seven  years  old,  fractured  external  condyle.  Five  years  after  the  fracture,  flexion  and 
extension  are  nearly  normal.  Pronation  and  supination  are  normal.  The  carrying  angle  is 
normal.    Treatment  in  acute  flexion. 

281 


Humerus.' — 


Radius. 


Ulna. 


P^S-  346.— Same  as  case  in  figure  345    The  elbow  is  flexed. 


Radius 


Ulna. 


Fig.  347. — X-ray.  Anteroposterior  view  of  the  extended  elbow  of  a  boy  eleven  years  old. 
When  about  six  years  old  he  suffered  a  compound  separation  of  the  lower  epiphysis  of  the 
humerus.  Four  and  one-half  to  five  years  after  the  accident  all  movements  are  normal.  The 
carrying  angle  is  slightly  less  than  normal  on  the  injured  side. 

282 


FRACTURES    OF    THE   HUMERUS 


283 


Humerus. 


Radius. 


Ulna. 


Fig.  348. — Same  case  as  that  in  figure   347.   The  elbow  is  flexed. 


A  glance  at  these  end-results  of  an  unselected  group  of  elbow- 
joint  injuries  occurring  in  childhood  will  convince  one  that, 
despite  the  absence  of  anatomical  perfection,  under  the  treatment 
advocated  the  results,  functionally,  are  satisfactory.  Perfect 
anatomical  results  are  to  be  sought  for.  With  the  assistance  of 
the  X-ray,  which  was  not  employed  when  the  above  cases  were 
under  treatment,  more  nearly  perfect  anatomical  results  could 
probably  have  been  obtained. 


CHAPTER  X 
FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

FRACTURES  OF  BOTH  RADIUS  AND  ULNA 

The  most  common  seats  of  fracture  are  in  either  the  middle 
or  lower  thirds  of  the  bones.  The  fracture  of  the  radius  is  often 
a  little  higher  than  the  fracture  of  the  ulna. 

S5rmptonis. — The  arm  can  not  be  used  without  pain.  In  a 
muscular  or  fat  arm  with  little  separation  of  the  fragments 
there  may  be  no  deformity  excepting  the  localized  swelling 
of  the  seat  of  fracture.  Deformity  will  be  determined  by  the 
displacement  of  the  bones.  If  the  seat  of  fracture  is  not  obvious, 
the  forearm  should  be  grasped  by  the  two  hands  (see  Fig.  362) 
and  gentle  but  firm  movement  attempted,  to  determine  the  pres- 
ence of  abnormal  motion  and  crepitus.  Motion  should  be 
attempted  in  all  directions,  for  the  bones  may  be  fractured  and 
yet  be  locked  when  movement  is  made  in  one  direction  only. 

Incomplete  or  Greenstick  Fracture  of  the  Bones  of  the 
Forearm  (see  Figs,  359-362). — This  is  a  partial  break  across 
the  bone,  with  bending  at  the  seat  of  fracture.  In  children  be- 
tween the  ages  of  two  and  fourteen  years  injury  to  the  bones 
of  the  forearm  results  usually  in  a  greenstick  fracture.  Either 
one  or  both  bones  may  be  broken.  One  bone  may  be  com- 
pletely fractured  while  the  other  is  incompletely  broken. 

Deformity  is  very  evident.     Pain  and  tenderness  at  the  seat 

of  fracture  are  present.     Crepitus  is  absent  unless  one  bone  is 

completely  fractured.     Children  having  these  fractures  are  often 

seen  a  week  or  two  after  the  injury ;  they  are  said  to  have  "sprained 

the  arm"  and  "are  unable  to  use  it  well  at  the  present  time." 

Careful  inspection  will  detect  the  characteristic  bowing  at  the 

seat  of  a  greenstick  fracture.     Slight  callus  will  be  present  if  a 

little  time  has   elapsed   since  the  injury. 

284 


FRACTURE  OF  NSCK  AND  HEAD  OF  RADIUS 


285 


Fracture  of  the  Neck  and  Head  of  the  Radius. — This 
fracture  of  the  upper  end  of  the  radius  is  being  discovered  more 
frequently  than  hitherto,  because  of  the  employment  of  the 
X-ray  in  doubtful  injuries  to  the  elbow.  The  fracture  is  obscure. 
It  is  little  recognized.  Upon  its  recognition  and  proper  treat- 
ment depend  possibly  the  integrity  of  the  elbow  and  wrist  move- 
ments of  pronation  and  supination. 

When  the  fracture  is  confined  to  the  head  of  the  radius  it  is 
wholly  intracapsular,  that  is,  within  the  orbicular  ligament.  The 
fragment  is  often  wedge  shaped.  The  fracture  is  longitudinal  in 
direction,  spHtting  the  edges  of  the  button-like  head  (see  Figs.  349, 


Fig.  349. — -Fracture  of  the  neck  of  the 
radius.  Anteroposterior  view.  The  arrow 
points  to  the  line  of  the  fracture. 


Fig.  350' — Fracture  of  the  neck  of  the  radius. 
Same  as  Fig.  349-  Lateral  view.  The  arrow 
points  to  the  line  of  the  fracture. 


351)°  A  fragment  is  rarely  completely  detached  from  the  capsule. 
It  is,  however,  possible  for  a  fragment  to  become  partially  or 
wholly  separated  and  to  lie  so  as  to  check  flexion  of  the  forearm 
or  so  as  to  hinder  pronation  and  supination. 

A  fall  forward  upon  the  outstretched  pronated  hand  with  elbow 
extended  is  the  usual  cause  of  this  fracture  of  the  upper  end  of  the 
radius. 

Why  the  head  in  one  case  and  the  neck  of  the  radius  in  another 
case  is  fractured  is  probably  due  to  the  varying  amount  and  direc- 
tion of  the  force  acting  through  the  shaft  of  the  radius. 

Diagnosis. — The  fracture  of  the  upper  end  of  the  radius  is 
often  associated  with  other  minor  or  major  injuries.     At  times 


286  Fractures  of  the  bones  of  the  forearm 

it  is  associated  with  fractures  of  the  external  condyle  of  the  hu- 
merus, with  dislocation  of  the  forearm  backward,  with  fracture  of 
the  coronoid  process  of  the  ulna,  with  dislocation  of  the  radius 
alone,  with  subluxation  of  the  radial  head.  If  any  of  these 
lesions  is  present  a  fracture  of  the  head  or  neck  of  the  radius 
should  be  looked  for  very  carefully,  although  in  the  presence  of 
severe  injury  to  the  elbow  region  the  radial  fracture  may  be  of 
secondary  importance.  If  the  neck  is  fractured  the  head  may 
not  rotate  with  the  shaft  of  the  bone. 

If  after  a  fall  upon  the  hand  there  is  pain  and  sw^elling  at  the 
outer  side  of  the  elbow  and  tenderness  upon  pressure  over  the 


Fig.  351- — Fracture  of  the  head  of  the  radius  in  an  adult.  Note  the  longitudinal  lines  of  fracture 
and  the  head  split  into  three  wedge-shaped  pieces.  Arrow  No.  3  points  to  lines  of  fracture.  Arrow 
No.  4  points  to  anteriorly  displaced  fragment.     See  also  Fig.  352.      (Porter). 

region  of  the  head  and  neck  of  the  radius,  and  the  movements 
of  complete  extension  and  flexion  are  limited  and  painful,  together 
with  limitation  and  pain  in  the  movements  of  pronation  and 
supination  especially,  and  if  other  injuries  enumerated  above  can 
be  excluded  the  diagnosis  may  be  made  of  an  injury  to  the  head  or 
neck  of  the  radius.  The  swelling  over  the  head  of  the  radius  will 
not  be  commensurate  with  the  pain,  and  often  great  impairment  of 
function  occasioned  by  a  fracture  of  the  radial  neck  or  head.  If 
crepitus  can  be  elicited  the  diagnosis  is  confirmed.  Many  physical 
conditions  may  prevent  crepitus  even  in  the  presence  of  a  fracture. 


FRACTURE  OF  NECK  AND  HEAD  OF  RADIUS 


287 


Fig.  352- — Fracture  of  the  head  of  the  radius  in  an  adult.  Note  the  longitudinal  characteristic 
splitting  of  the  head  at  arrow  No.  2.  Note  the  fragment  displaced  forward  at  arrow  No.  ii  Recovery 
with  flexion  and  extension  limited  (Porter). 


Radial  head. 


Radial  shaft. 


A  /  /-->   s  Greater  sigmoid  cavity 


Ulna  shaft. 


Fig.  353- — Common  displacement  in  fracture  of  the  neck  of  the  radius  (after  Mouchet). 

If  the  fracture  is  overlooked  and  treated  as  a  contusion  or  a  sprain 
there  may  be  subsequent  non-union  or  Hmitation  of  joint  motion; 
this  latter  is  dependent  upon  excessive  callus  formation  and  ad- 


288 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


hesions.  Persistent  impairment  of  the  motions  dependent  upon 
the  integrity  of  the  radio-humeral  and  radio-ulnar  articulation  will 
be  the  best  evidence  of  injury  to  the  radial  head  or  neck. 


Seat  of  fracture 
in  radius. 


Radial  epiphysis. 


Seat  ot  fracture 
in  ulna. 


_  Ulna  epiphysis. 


Fig.  354- — Fracture  of  both  bones  of  the  forearm  above  wrist.     A  not  uncommonly  overlooked 
and  frequent  injury  (Children's  Hospital,  P.  Brown). 


P^DlUS 


VLNK 


Fig-  355- — Fracture  of  head  of  radius  with  anterior  luxation  of  the  radius.     Lateral  view  (Thomas). 

Prognosis. — The  superior  radio-ulnar  articulation  and  the  upper 
surface  of  the  cup-shaped  head  being  involved  in  this  variety  of 
fracture,  limitation  in  pronation  and  supination  and  in  flexion  and 
extension  of  the  forearm  is  a  possible  result. 


FRACTURE  OF  NECK  AND  HEAD  OF  RADIUS 


289 


Under  proper  treatment  an  uncomplicated  fracture  of  the  head 
or  neck  of  the  radius  should  result  in  union  of  fragments  and 
normal  function  of  the  part. 


Fig.  3s6. — Fracture  of  head  with  post-luxation  of  elbow  (Thomas). 


Fig.  357- — Fracture  of  both  radius  and 
ulna  in  lower  third.  Xcte  tendency  of  lower 
fragments  to  come  together  and  of  upper 
fragments  to  separate. 


Fig.  358. — Fracture  of  both  radius  and 
ulna.  Note  tendency  for  all  fragments  to 
separate  and  bend  outward  away  from 
midline  of  forearm. 


Treatment. — As  Thomas  suggests,  union  should  be  sought  first 
and  motion  secured  afterward.  Immobilization  of  the  elbow  for 
from  2^  to  4  weeks,  usually  at  a  right  angle,  is  indicated  together 
with  massage  immediately  after  the  injury. 

if  the  fragments  are  widely  separated  the  orbicular  ligament 
19 


290 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


is  probably  torn  and  immediate  operation  upon  the  subsidence 
of  the  primary  swelhng  is  wise. 

In  operating  the  fragments  of  bone  will   be    removed  and  if 


Fig.  359- 
ity 


-Separation  of  lower  radial  epiphysis.     Note  the  dorsal  displacement  and  deform- 
seen  in  outline  and  that  there  is  little  lateral  displacement  (M.  G.  H.,  Dodd). 


Fig.  360. — Note  lateral  displacement  of  separated  lower  radial  epiphysis.     Child  about  eight 
years  old  (M.  G.  H.,  Dodd). 

wise  when  the  exact  conditions  are  seen  a  complete  resection  of 
the  head  of  the  radius  done. 

After  the  immobilizing  splint  is  removed  the   elbow  will  be 


FRACTURE  OF  NECK  AND  HEAD  OF  RADIUS 


291 


found  to  be  pretty  stiff  and  useless.  Gentle  massage  and  passive 
motion,  and  attempts  at  active  motion  should,  within  four  to 
eight  weeks,  result  in  approximately  normal  elbow  movements. 


Fig.  361, — Note  dorsal  displacement  of  separated  lower  radial  epiphysis.     Cliild  about  eight 
years  old  (M.  G.  H.,  Dodd). 


Fig.  .362.  — Manner  of  grasping  forearm  to  detect  the  presence  of  fracture.     Note  the  firmness 

of  grasp. 

Operation  should  be  undertaken  in  those  recent  cases  in  which 
there  is  separation  of  fragments,  and  in  those  overlooked  old  cases 
in  which  non-union  and  adhesions  and  excessive  callus  forma- 
tion and  a  displaced  fragment  have  resulted  in  impairment  of 
the  usefulness  of  the  forearm  and  elbow. 


292 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


Fracture  of  the  Shaft  of  the  Radius  (see  Figs.  365-369 
inclusive). — This  is  usually  caused  by  direct  violence.  The  frac- 
ture occurring  at  any  part  of  the  shaft  presents  no  unusual 
symptoms.     The  head  of  the  bone  does  not  rotate  with  the  shaft 


>.■      i^^'mmet.'^^  ■  ■ 

^1 

K^ 

1 

^^^^^^^^Kc:£irji^ 

^2^^^ 

%: 

Fig.  363. — Greenstick  fracture  of  both  bones  of  the  right  forearm.     Note  uniform  bending  of  the 

forearm. 


Fig.  364. — Greensticlc  fracture  of  both  bones  of  the  forearm  of  a  child.     Same  as  Fig.  363. 


unless  the  fragments  are  locked.  Abnormal  mobility,  pain,  and 
crepitus  are  present.  The  displacements  vary  with  the  situation 
of  the  fracture.     Pronation  and  supination  will    be  limited  and 


I^RACTURE    OF    NECK   AND    HEAD    OF    RADIUS 


293 


painful.  This  fracture  has  been  mistaken  for  a  subjugation  of 
the  radial  head.  A  fracture  of  the  radial  shaft  at  the  junction 
of  the  lower  and  middle  thirds  will  sometimes  suggest  very  plainly 
the  lateral  deformity  in  a  Colles'  fracture,  the  prominent  ulna 
and  apparently  shortened  styloid  process  of  the  radius  being  in 


Fig.  365. — Lateral  view  of  a  greenstick  fracture  of  the  radius. 


Fig.  366. — Green-stick  fracture  of  the  ulna. 
Arrow  points  to  the  site  of  fracture.  Note  the 
bending  of  both  radius  and  ulna  and  crack 
in  convexity  of  the  bent  ulna. 


Fig.  367. — ("1  mi  minuted  fracture  of  radius. 
An  unusual  type  more  often  seen  in  the  lower 
leg. 


evidence.     If  the  fracture  occurs  in  the  upper  third  of  the  bone, 
the  displacement  of  the  upper  fragment  will  be  considerable. 

Separation   of  the  Lower  Epiphysis   of  the  Radius. — The 
lower  radial  epiphysis  unites  to  the  shaft  of  the  bone  at  the 


294 


SEPARATION    OF   LOWER    EPIPHYSIS 


295 


twentieth  year.  Previous  to  this  age  a  separation  of  the  epiphy- 
sis is  not  at  all  uncommon.  Many  cases  of  separation  of  this 
epiphysis  are  thought  to  be  Colles'  fractures,  and  they  are  treated 
as  such.  The  treatment  of  a  Colles'  fracture  may  present  con- 
siderable difficulties.  Ordinarily  the  treatment  of  a  separation 
of  this  epiphysis  is  simple.  There  is  little  difficulty  in  main- 
taining the  fragments  in  position  in  separation  of  the  epiphysis. 
The  epiphyseal  separation  requires  a  short  time  in  splints. 


Fig.  370. — Transverse  fr;icture  of  the  ulnar  and  radius.     Much  displacement  of  ulnar  fragment. 

A  soft,  cartilaginous  crepitus  is  felt.  There  are  usually  less 
swelling  and  less  pain  than  in  a  Colles'  fracture.  The  deformity 
is  quite  constant :  •  a  prominence  near  the  carpus  on  the  dorsum 
of  the  vmst  and  a  prominence  higher  up  on  the  palmar  surface 
of  the  wrist.  There  is  almost  no  tendency  to  reproduction  of 
the  deformity  after  it  is  once  reduced. 

Fracture  of  the  shaft  of  the  ulna  occurs  usually  because  of 
a  direct  blow  received  upon  the  arm  raised  for  protection.  It  is 
more  uncommon  than  fracture  of  the  radius  (see  Fig.  366). 

Localized  tenderness,  pain  upon  attempting  to  use  the  fore- 
arm, obscure  discomfort  in  the  arm  after  an  injury — these  may 
be  the  only  signs  of  fracture.  There  is  no  general  swelling  of 
the  forearm.  Ordinarily,  there  will  be  very  little  displacement, 
because  the  radius  serves  as  a  splint  for  the  broken  bone.     Crepitus 


296       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

may  be  detected  if  the  ulna  is  grasped  between  the  fingers,  placed 
either  side  of  the  fracture,  and  motion  is  attempted.  The  shaft 
of  the  ulna  being  subcutaneous  throughout  its  entire  extent, 
the  tender  seat  of  fracture  can  easily  be  determined. 

Fracture  of  the  coronoid  process  of  the  ulna  is  associated 
with  backward  dislocation  of  the  ulna.  It  is  a  rare  accident. 
A  very  small  fragment  is  broken  off,  and  it  is  not  much  displaced. 
If  in  any  dislocation  of  the  forearm  backward  recurrence  of  the 
deformity  after  reduction  occurs  readily,  a  fracture  of  the  coro- 
noid should  be  suspected.  This  will  be  confirmed  by  the  dis- 
covery of  a  small  hard  mass  in  front  of  the  elbow-joint  just 
above  the  insertion  of  the  brachialis  anticus  muscle;  roughly, 
a  finger-breadth  above  the  bend  of  the  elbow.  This  small  hard 
mass  may  give  crepitus  upon  being  manipulated.  It  is  very 
difficult  to  detect  this  fragment  of  the  coronoid  process  even 
under  the  most  favorable  conditions.  The  Rontgen  ray  may 
discover  it. 

Treatment  of  Fractures  of  the  Forearm. — The  objects 
of  treatment  are  to  prevent  permanent  deformity  and  to  pre- 
serve the   movements  of  pronation   and   supination. 

Fractures  of  Both  Radius  and  Ulna. — All  fractures  of  the  fore- 
arm attended  with  overriding  or  angular  displacement  that  do 
not  yield  readily  to  traction,  countertraction,  and  pressure 
should  be  reduced  under  complete  anesthesia.  While  an  as- 
sistant makes  countertraction  upon  the  upper  part  of  the  forearm 
the  surgeon,  holding  the  lower  end  of  the  limb,  makes  strong, 
even  traction,  at  the  same  time  pressing  the  bones  into  position. 
When  the  angular  deformity  is  corrected,  the  forearm  should 
be  strongly  supinated.  This  supination  will  assist  in  preventing 
the  bones  becoming  locked  close  together  (see  Fig.  377)' 

In  order  to  immobilize  a  fracture  of  the  shaft  of  a  bone  not 
only  must  the  fracture  itself  be  held  firmly,  but  the  joint  im- 
mediately above  and  below  the  seat  of  fracture  nmst  be  im- 
movably fixed.  If  the  arm  is  seen  immediately  after  the  ac- 
cident, and  the  soft  parts  are  not  evidently  bruised,  and  there 
is  little  swelling,  a  plaster-of- Paris  splint  should  be  applied. 
It  should  extend  from  the  axilla  above  to  the  metacarpopha- 
langeal joints  below.  The  arm  should  be  flexed  to  a  right  angle 
and  the  forearm  semisupinated  (thumb  upward)   (see  Fig.  378). 


TREJATMENT 


297 


Precautions  in    Using  the   Plaster-of- Paris  Splint:   The    fore- 
arm  should   be  held  in   the   corrected  position  by  an  assistant 


Fig.  371. — Same  as  Fig.  370.     Lateral  view.     Note  the  anteroposterior  deformity.     An  X-ray  should 
always  be  taken  in  at  least  two  planes. 


Fig.  372. — Greenstick  fracture  of  ulna  and  raflius.     Lateral  view  of  Fig.  373- 


Fig.  373. — Lateral  view  of  Fig.  372.  Note  the  considerable  displacement  of  fragments.  A  difficult 
fracture  to  reduce  and  hold  reduced  unless  the  fragments  can  be  locked  in  position.  Almost  impossible 
to  lock  fragments  of  both  bones  without  an  incision  and  digital  pressure. 

throughout  the  application  of    the  plaster    bandages.     Two  as- 
sistants will  facilitate  the  putting  on  of  the  plaster.     The  fore- 


298 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


arm  should  be  held  in  the  corrected  position  by  an  assistant 
throughout  the  application  of  the  plaster  bandages.  Two  as- 
sistants will  facilitate  the  putting  on  of  the  plaster.  The  fore- 
arm and  upper  arm  should  be  thinly  covered  with  one  layer  of 
sheet  wadding;  cotton  wadding  should  not  be  used.  No  salt 
should  be  used  in  the  water  in  which  the  plaster  bandages  are 
dipped.  It  will  require  about  three  or  four  bandages,  three 
inches  wide  and  four  yards  long,  for  an  ordinary  muscular  adult 
arm.  The  plaster  roller  should  be  applied  deliberately,  evenly, 
and  snuglv  from  the  metacarpophalangeal  joints  to  the  axilla. 
Great  lateral  compression  of  the  arm  will  be  avoided  if  the  ban- 
age  is  applied  as  directed.  There  will  be  insufficient  compres- 
sion to  crowd  the  bones  together  and  so  produce  deformity. 


■ 

t 

1 

Fig.  374. — Fracture  of  radius.     Little  apparent 
displacement. 


tig.  575. — I'racturc  of  shaft  of  radius.  Lat- 
eral view  of  Fig.  374.  Real  displacement  seen 
in  this  view. 


After-care  of  the  Plaster  vSplints:  When  the  plaster  has  set 
firmlv,  the  assistant  ma}^  place  the  forearm  in  a  sling  of  com- 
fortable height  to  support  the  arm.  Inspection  of  the  fingers 
will  determine  the  condition  of  the  circulation  in  the  limb.  If 
there  is  too  great  pressure,  if  the  splint  is  too  tight,  a  blueness 
will  appear,  indicating  a  sluggishness  in  the  circulation.  If 
this  sign  appears,  the  splint  should  immediately  be  split  from 
axiha  to  hand  by  a  knife.  This  will  relieve  the  circulation. 
Ordinarily,  there  is  no  difficulty  of  this  sort.     The  patient  should 


Treatment 


299 


be  seen  each  day  for  the  first  week  after  the  dressing  is  put  on. 
Inquiry  should  be  made  for  pain  and  throbbing  in  the  arm  and 
sleeplessness,  which  are  evidences  of  too  great  pressure.  If  the 
arm  is  doing  well,  the  splint  should  cause  no  discomfort.  After 
one  w^eek  the  plaster  splint  should  be  removed,  for  the  swelling 
of  the  arm  will  have  diminished  and  the  splint  will  have  become 


Fig.  376. — Variations  in  the  shape  and  width  of  the  interosseous  space  between  radius 
and  ulna  when  the  forearm  is  semipronated,  supinated,  and  pronated.  Semipronation  pre- 
sents the  widest  interosseous  space. 


loosened.  Unless  this  loosening  is  corrected,  an  opportunity 
for  deformity  to  occur  will  then  exist.  Either  a  new  plaster 
should  be  applied  or  the  old  splint,  if  suitable,  should  be  reapplied 
and  tightened  by  a  bandage.  If  the  splint  is  too  large,  it  may 
be  made  smaller  by  removing  a  strip  of  plaster  the  entire  length 
of  the  splint.  The  edges  of  the  cut  plaster  should  be  bound 
with  strips  of  adhesive  plaster  to  prevent  chafing  of  the  skin 


300 


FRACTURES  OF  THK  BONES  OF  THE  FOREARM 


and  crumbling  of  the  plaster.  The  position  of  the  bones  at  the 
seat  of  fracture  should  be  noted.  The  degree  of  movement 
possible  at  the  seat  of  fracture  should  be  noted.  At  the  end  of 
each  week  the  splints  should  be  removed.  After  about  three 
weeks,  when  union  is  well  advanced,  the  plaster  splint  may  be 


Fig.  377 Fracture  of  the  forearm  low  down,  or   Colles'  fracture.     Anterior  and  posterior 

splints,  three  straps,  radial  pad.     Anterior  splint  cut  out  to  fit  thenar  eminence. 


Fig.  3'/S. — Fracture  of  the  forearm.     Manner  of  holding  arm  and  of  applying  the  adhesive- 
plaster  straps.     Posterior  splint  of  splint  wood. 


cut  off  below  and  the  upper  part  discarded,  or  a  posterior  splint 
of  wood  may  be  applied  for  lightness  and  convenience. 

If  the  force  was  a  direct  violence  and  there  is  injury  to  the 
soft  parts,  if  the  swelling  is  considerable  and  is  likely  to  be  greater, 
it  will  be  best  to  use  palmar  and  dorsal  splints  of  wood  upon  the 
forearm  and  an  internal  right-angle  splint  at  the  elbow.     The 


TREATMENT 


301 


forearm  is  held  in  the  position  of  semisupination.  The  maximum 
swelling  occurs  within  the  first  forty-eight  hours — barring,  of 
course,  inflammatory  disturbances,  which  are  not  to  be  con- 
sidered here.  The  splints  should  be  of  thin  splint  wood,  which 
is  stiff  enough  not  to  yield  to  ordinary  pressure.  In  width 
they  should  be  one-fourth  of  an  inch  wider  than  the  forearm. 
The  posterior  splint  should  extend  from  just  above  the  middle 
of  the  forearm  to  the  metacarpophalangeal  joints.     The  anterior 


Fig.  379- — Fracture  of  both  bones  of  the  forearm.     Proper  position  of  arm  in  sling.     Notehand 
is  unsupported  by  sling,  and  arm  rests  on  ulnar  side.     Notice  height  of  arm. 


splint  should  extend  fiom  the  same  point  on  the  forearm  to  the 
middle  of  the  palm  of  the  hand  (see  Fig.  377).  The  palmar 
splint  is  cut  out  on  the  thumb  side,  so  as  to  avoid  pressure  on 
the  thenar  eminence.  These  two  splints  are  padded  with  evenly 
folded  sheet  wadding  no  wider  than  the  splints.  About  three 
or  four  thicknesses  of  the  sheet  wadding  will  be  necessary.  The 
posterior  splint  is  padded  alike  through  its  whole  extent.  The 
anterior  splint  is  so  padded  as  to  conform  to  the  irregularities 
of  the  anterior  surface  of  the  forearm,  particularly  at  the  radial 


302 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


side  near  the  wrist.  The  internal  right-angle  splint  is  padded 
evenly  with  four  thicknesses  of  sheet  wadding.  It  overlaps 
the  wooden  splints,  and  extends  up  to  the  axilla.  It  immobilizes 
the  elbow-joint. 

The  Application  of  the  Splints:  The  forearm  is  held  flexed  at 
a  right  angle  and  semisupinated  and  steadied  by  an  assistant. 
The  posterior  and  then  the  anterior  splints  are  applied  to  the 
forearm.  Three  straps  of  adhesive  plaster,  two  inches  broad, 
are  then  applied — one  at  the  upper  ends  of  the  splints,  one  at  the 
wrist,  and  the  third  across  the  palm  of  the  hand  and  around 


Fig.  3S0. — Fracture  of  both  bones  of  the  forearm.  Uhiarviewof  the  anterior  and  posterior 
splints.  Note  length  of  spHnts  and  position  of  straps.  Straps  of  the  internal  right-angle 
splint,  3  and  4. 


the  posterior  splint  only.  These  straps  should  simply  steady 
the  splints  snugly  in  position  (see  Fig.  378).  The  bandage  is 
next  applied,  and  it  is  by  this  that  pressure  is  exerted  upon  the 
arm.  There  should  be  some  spring  left  upon  pressing  the  splints 
together  after  the  bandage  is  applied.  If  there  is  none  remaining, 
too  great  pressure  will  be  made  on  the  arm  and  the  circulation 
will  be  interfered  with.  The  arm  is  placed  in  a  sling  of  com- 
fortable height   (see  Fig.  379). 

If  the  fracture  of  the  forearm  is  above  the  middle  of  the  bones, 
the  tin  internal  right-angle  splint  should  be  used  to  immobilize 


TREATMENT 


303 


the  elbow-joint.  This  should  be  applied  after  the  wooden 
splints  are  in  place  and  while  the  arm  is  semisupinated.  A 
bandage  is  then  placed  over  both  wooden  and  tin  splints 
(see  Figs.  380,  381,  382). 

After-care  of  Wooden  and  Tin  vSplints :  The  patient  should  be 
seen  everv  day  for  two  or  three  days  after  the  fracture.  The 
splints  should  be  readjusted  and  applied  more  snugly  by  a  fresh 
bandage.  The  comfort  of  the  patient  _  should  be  considered ; 
any  complaint  on  the  part  of  a  sensible  individual  should  be  in- 


Fig.  381. — Fracture  of  the  bones  of  forearm.  Forearm  supinated.  Anterior  and  posterior 
splints  and  tin  internal  angular  splints,  i  and  2,  Straps  holding  anterior  and  posterior  splints ; 
3.  4,  and  5,  straps  holding  internal  right-angle  splint. 


quired  into.  If  the  apparatus  is  applied  with  the  bones  in  ap- 
proximately normal  position,  there  should  be  no  subsequent 
discomfort.  All  splints  should  be  removed  at  least  tvvice  a  week 
throughout  active  treatment,  and  the  presence  of  deformity 
noted  and  corrected.  After  the  first  week  and  a  half,  the  swell- 
ing having  subsided,  it  is  often  advantageous  to  apply  in  place 
of  these  splints  of  wood  the  plaster-of- Paris  splint,  which  has 
been  described. 

Fracture  of  the  head  and  neck  of  the  radius  and  fracture  of  the 


304 


FRACTURES  OF  THE)  BONES  OF  THE  FOREARM 


coronoid  process  of  the  ulna  should  be  treated  by  the  internal 
right-angle  splint  with  the  forearm  semipronated — that  is,  with 
the  thumb  up  (see  Fig.  382). 

Fracture  of  the  shaft  of  the  radius,  if  above  the  middle  of  the 
bone,  should  be  treated  by  the  anterior  and  posterior  wooden 
splints  and  the  internal  right-angle  splint.  If  below  the  middle 
of  the  bone,  the  internal  right-angle  splint  may  be  omitted,  al- 
though it  may  be  well  to  retain  it  in  most  instances.  If  the 
fracture  is  in  the  upper  third  of  the  bone,  it  may  be  impossible 
to  correct  the  deformity  without  making  an  open  fracture  and 
suturing   the   fragments   together.     It   may   be   possible   to    ap- 


Fig.  382. — Fracture  of  both  bones  of  the  forearm.  Anterior  and  posterior  splints  and  tin 
internal  right-angle  splint  immobilizing  elbow-joint.  Note  arm  in  semipronalion,  "  thumb 
up  "  ;  position  of  straps  ;  padding  of  internal  right-angle  splint. 


proximate  the  fragments  by  putting  the  forearm  in  a  position 
of  semipronation.  No  special  splint  is  necessary  to  maintain 
this  position;  the  two  wooden  anterior  and  posterior  splints  and 
the  tin  internal  right-angle  splint  fulfil  all  the  indications. 

Separation  of  the  lower  radial  epiphysis  is  treated  by  anterior 
and  posterior  splints,  like  those  used  in  the  treatment  of  a  Colles' 
fracture  (see  Fig.  394). 

Fracture  of  the  shaft  of  the  ulna  should  be  treated  as  fractures 
of  the  shaft  of  the  radius  are  treated- 

How  long  should  splints  be  kept  on  in  fractures  of  the  fore- 
arm?    Until  union  is  firm  enough  between  the  fragments,   so 


TREATMENT  3O5 

that  firm  pressure  does  not  cause  motion.  When  the  fracture 
is  firm,  ordinarily  after  about  three  weeks  and  a  half,  the  anterior 
and  internal  angular  splints  may  be  omitted,  the  posterior  splint 
alone  being  left  in  place.  If  the  posterior  splint  of  wood  is  used, 
a  broad  (four-inch)  strap  of  adhesive  plaster,  in  addition  to  the 
two  ordinary  straps  at  each  end  of  the  splint,  should  be  placed 


Fig.  383. — Application  of  sling.  Proper  position  of  triangular  bandage  in  first  step.  2  is 
carried  over  right  shoulder ;  i  drops  over  left  shoulder  ;  i  and  2  are  fastened  behind  the  neck  ; 
3  is  brought  forvv'ard  and  pinned,  as  shown  in  figure  384. 


at  the  seat  of  fracture  and  a  gauze  bandage  applied  over  all.  At 
the  end  of  the  fourth  or  fifth  week  all  splints  should  be  omitted. 
Continual  watchfulness  is  demanded  in  order  that  bowing  at  the 
seat  of  fracture  may  not  take  place.  The  application  of  the 
sling  after  the  omission  of  splints  should  be  carefully  made  to 
avoid  backward  bowing  of  the  bones.  A  laboring  man  should 
not  go  to  work  for  at  least  from  four  to  six  weeks  after  leaving 
20 


3o6      FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

oflf  splints.  A  return  to  work  too  early  causes  bowing  of  the 
fracture  and  pain  in  the  arm. 

Massage  and  passive  motion  should  be  employed  as  soon  as 
union  is  firm  and  the  anterior  and  internal  angular  splints  have 
been  removed.  Massage  may  be  given  at  first  without  removing 
the  arm  from  the  splint.  Convalescence  will  proceed  more 
rapidly  in  consequence  of  massage. 

When  will  the  arm  be  restored  to  normal  usefulness.''     It  is 


Fig.  384.^Application  of  sling.     Final  position  of  arm.     Two  ends  tied  behind  neck  and  the 

third  end  pinned. 


impossible  to  answer  this  question  accurately.  The  conditions 
in  each  individual  instance  of  fracture  are  so  variable  that  no 
general  statement  can  be  made  that  will  more  than  indicate 
the  probable  time  of  convalescence.  It  may  be  fairly  stated  that 
in  an  uncomplicated  fracture  of  both  bones  of  the  forearm  the 
arm  will  be  useful  for  working  in  from  two  to  three  months  from 
the  time  of  fracture. 

The  treatment  of  open  fractures  of  the  forearm  is  best  con- 


PROGNOSIS    AND    RESULT   OF   TREATMENT  307 

ducted  by  methods  described  under  open  fractures  of  the  leg: 
briefly,  absolute  cleanliness,  suturing  of  bones,  sterile  dressing, 
immobilization  of  the  part. 

Prognosis  and  Result  of  Treatment. — There  may  be  some 
limitation  of  supination  and  pronation  immediately  after  the 
splints  are  removed.  As  the  callus  diminishes  and  with  per- 
sistent movements  of  the  arm  in  ordinary  use  this  limitation 
should  diminish,  and  in  some  instances  entirely  disappear.  If 
the  fracture  is  in  the  upper  or  lower  thirds  of  the  bones,  the 
limitation  of  motion  will  often  be  greater  than  when  the  fracture 


Fig.  385. — Compound  fracture  and  dislocation  at  the  wrist.     Hand  saved. 

is  at  the  middle  of  the  bones.  The  interosseous  space  is  greatest 
at  the  middle  of  the  shafts  (see  Fig.  376) ;  consequently,  callus 
at  this  point  is  less  likely  to  impair  motion  of  the  forearm.  The 
arm  should  be  straight.  Movements  of  the  wrist  and  elbow 
should  be  perfectly  normal. 

Nonunion  of  Fractures. — If  after  the  usual  time  has  elapsed 
for  a  fracture  to  have  united  firmly  it  has  failed  of  union,  de- 
layed union  is  said  to  exist.  If  after  a  longer  time  no  union 
occurs,  nonunion  is  said  to  exist.  A  case  of  delayed  union  may 
result  in  nonunion  or  it  may  become  united.     The  term  non- 


308      FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


Fig.  386. — Transverse  fracture  of  the  radius  and  ulna  with  slight  displacement. 


Fig.  387. — Fracture  transverse  subperiosteal  of  both  radial  and  ulna  shafts.     No  lateral  gross  de- 
formity. 


PROGNOSIS  AND  RESULT  OF  TREATMENT 


309 


Fig.  388. — Transverse  fracture  of  radius  subperiosteal. 


ViK.  38y.— Old  ununited  fracture  of  the  radius.  Xotc  tlic  spate  between  the  fragments,  the  abduc- 
tion of  the  whole  hand,  the  shortening  of  the  radial  side  of  the  arm,  the  atrophy  and  thinning  of  the 
bone  of  the  carpus,  and  the  two  radial  fragments  as  indicated  by  the  light  shadow  of  these  parts. 


3IO       FRACTURES  OF  THF  BONES  OF  THE  FOREARM 

union  does  not,  however,  necessarily  imply  that  no  union  exists 
between  the  bones,  but  simply  that  bon}^  union  does  not  exist. 
In  cases  of  so-called  nonunion  fibrous  union  is  often  present. 
The  causes  of  nonunion  are  local  and  general.  Of  the  local  causes 
the  commonest  is  the  interposition  of  some  soft  tissue,  such  as 
torn  periosteum,  strips  of  fascia  or  muscle,  between  the  frag- 
ments. A  wide  separation  and  imperfect  immobilization  of 
the  fragments  are  also  factors  in  the  occurrence  of  nonunion. 
Of  the  general  causes  it  is  thought  that  syphilis,  pregnancy,  pro- 
longed lactation,  the  wasting  diseases,  rachitis,  and  the  acute 
febrile  diseases  may  contribute  something  toward  nonunion. 

The  constitutional  treatment  of  nonunion  is  of  primary  im- 
portance, together  with  reduction  and  absolute  immobilization 
of  the  fragments.  If  these  measures  fail  after  a  fair  trial,  a 
rubbing  of  the  ends  of  the  fractured  bones  together  and  then 
immobilizing  them  is  sometimes  effective.  If  this  fails  too, 
operative  measures  should  be  instituted  for  making  the  fracture 
an  open  one  for  the  removal  of  any  interposed  tissues.  Careful 
fixation  will,  after  such  operative  procedure,  usually  effect  union. 
If  for  some  unremediable  constitutional  reason  union  does  not 
result  after  operation,  a  splint  should  be  devised  to  make  the 
damaged  part  as  useful  as  is  compatible  with  nonunion. 

Treatment  of  Greenstick  or  Incomplete  Fracture  of  the  Bones  of 
the  Forearm. — It  is  impossible  to  maintain  the  correction  of  the 
deformity  if  the  bones  are  simply  bent  back  into  position.  Even 
with  the  greatest  care  in  the  use  of  pads  and  pressure  the  de- 
formity will  in  part  reappear.  It  is  necessary,  therefore,  to 
administer  an  anesthetic,  and  to  make  a  complete  fracture  of 
the  greenstick  fracture.  This  done,  the  arm  is  set  as  in  a  com- 
plete fracture.  The  best  method  of  refracturing  the  greenstick 
fracture  is  to  bend  the  arm  with  the  two  hands  in  the  direction 
of  the  original  force. 

The  anterior  and  posterior  wooden  splints  may  be  used  with 
satisfaction.  Ordinarily,  the  plaster-of- Paris  splint  as  applied 
in  complete  fractures  is  the  best  apparatus.  Union  in  children 
after  fracture  is  more  rapid  than  in  adults.  At  the  end  of  two 
weeks  union  will  be  found  firm.  It  is  well  not  to  omit  all  ap- 
paratus in  a  child  until  four  weeks  have  passed.     If  great  caution 


FRACTURES  OF  THE  OLECRAXOX 


311 


is  needed  on  account  of  an  extremely  active  child,  the  posterior 
wooden  splint  should  be  kept  on  during  the  fifth  week. 


Head  of  _ 

radius. 


Lower  end  of 

humerus. 


Sigmoid  Olecranon  process. 

fossa 
of  ulna. 

p-ig_  3go.— Note  the  great  sigmoid  cavity  and  its  relation  to  the  olecranon  process  of  the  ulna. 
Almost  all  fractures  of  the  olecranon  are  intra-articular. 


Seat  of  fracture. 
Fig.  391.— Splintered  fracture  of  olecranon  without  much  displacement  (Massachusetts  Gets- 
eral  Hospital,  1536.    X-ray  tracing). 


FRACTURES  OF  THE  OLECRANON 
The  normal  anatomical  relations  of  the  olecranon  should  be 
kept  constantly  in  mind.     The  insertion  of  the  brachialis  anticus 


312 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


muscle  is  into  the  front  and  lower  part  or  base  of  the  coronoid 
process  of  the  ulna.     The  insertion  of  the  triceps  muscle  is  into 


Radius. 


Coronoid  process. 


Ulnar  shaft. 


Humerus. 


Olecranon. 


Seat  of  fracture. 


Fig.  392 — Fracture  of  olecranon.     No  displacement  detected  clinically.     No  symptoms  other 
than  local  tenderness  and  slight  swelling  (X-ray  tracing). 


Humerus. 


Olecranon. 


Ulnar  shaft. 
Fig.  393- — Fracture  of  olecranon  ;  separation  of  fragments  upon  flexing  forearm  (X-ray 

tracing.) 


the  posterior  part  of  the  upper  surface  of  the  olecranon  and 
into   the  fascia  of  the  posterior  surface  of  the   forearm.     The 


FRACTURES  OF  THE  OLECRANON 


313 


small  epiphysis  of  the  olecranon  unites  to  the  shaft  about  the 
sixteenth   year.     A    direct    blow   upon   the    olecranon   together 


Line  of  fracture. 
F'g-  394- — Fracture  of  olecranon  at  about  the  epiphyseal  line,  without  opening  the  elbow-joint 
(Massachusetts  General  Hospital,  1172.     X-ray  tracing). 


FJK.  395. — Fracture  of  tip  of  olecranon. 
No  displacement  of  fragment  in  extended 
position  of  forearm. 


Fig.  396. — Fracture  of  olecranon.  Note 
separation  of  fragments  in  flexed  position 
of  forearm. 


with  violent  muscular  contraction  of  the  triceps  v/ill  produce 
the  fracture.      The  fracture  is  usually  transverse.      A  complete 


Fig.  397. — Common  fracture  of  olecranon.     Note  situation  and  direction  of  fracture. 


^ 

:;1^ 

i^' 

7?acCA.-*^c<L 

'^^Hh' 

Ojetc^o^.,^ 

Fig.  398. — Fracture  of  the  shaft  of  the  ulna  extending  back  into  the  joint.     An  unusual  type 

of  ulna  fracture. 


Fig.  399.— A  comminuted  fracture  of  the  olecranon.     A  rather  uncommon  type  of  fracturis. 


FRACTURES  OF  THE  OLECRANON 


315 


transverse  fracture  of  the  olecranon  always  opens  the  elbow- 
joint  (see  Fig.  385).  Some  of  the  varieties  of  fracture  of  the 
olecranon  are  seen  in  the  accompanying  tracings  of  Rontgen-ray 
plates  (see  Figs.  391,  392,  393,  394),  and  in  the  X-rays  397,  398, 

399- 

Symptoms. — Inability    forcibly    to    extend    the   forearm,    pain 
at  the  seat  of  fracture,  and  deformity,   provided  the  fragment 


Fig.  400. — Fracture  of  the  olecranon.     Arm  in  extension.     Long  anterior  splint.     Note  pad 
and  strap  above  olecranon  fragment ;  pad  in  palm  of  hand. 


is  separated  from  the  shaft  of  the  ulna.  A  depression  marks 
the  separation.  Very  great  separation  of  the  fragment  is  not 
often  present.  The  interval  between  the  fragments  depends 
upon  three  conditions:  The  extent  of  the  facial  laceration — if 
the  laceration  is  moderate  in  extent,  the  interval  between  the 
fragments  will  be  slight;  if  the  laceration  is  extensive,  the  in- 
terval between  the  fragments  may  be  great;  the  position  of  the 


3l6       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

arm,  whether  flexed  or  extended — if  flexed,  the  separation  will  be 
greater  than  if  extended  (see  Figs.  395,  396)  the  amount  of  33010- 
vial  fluid  and  blood  in  the  joint — the  greater  the  amount  of  fluid, 
the  greater  will  be  the  separation  of  the  fragments.  The  mobility 
of  the  fragments  of  the  olecranon  is  determined  by  grasping  the 
olecranon  firmly  and  attempting  lateral  motion  (see  Fig.  248). 


Fig.  401. — Fracture  of  olecranon.     Arm  in  extension.     Note  upper  and  lower  straps  ;  oblique 
olecranon  strap  ;  padding  of  splint. 


Crepitus  may  thus  be  elicited.  The  general  swelling  about  the 
elbow  will  be  considerable  if  the  traumatism  was  severe.  There 
exists  a  traumatic  synovitis  of  the  elbow-joint. 

Treatment. — If  there  is  considerable  swelling  of  the  elbow, 
and  if  the  arm  is  large  and  muscular,  it  is  wise  to  rest  the  arm 
for  a  few  days  (at  least  five  or  six)  upon  an  internal  right-angle 
splint  before  putting  it  up  permanently.     The  swelling  will  dis- 


TREATMENT 


317 


appear  in  the  mean  time,  and  a  more  accurate  examination  of 
the  arm  can  then  be  made.  If  there  is  httle  or  no  separation 
of  the  fragments  in  the  right-angle  position,  the  arm  may  be 
kept  at  a  right  angle.  This  is  doubtless  the  most  comfortable 
position,  and,  under  these  conditions,  certainly  is  effective.  If 
there  is  marked  separation  (half  an  inch  or  more),  the  arm  should 


Fig.  402. — Fracture  of  olecranon.     Bandage  applied  to  the  same  case  as  shown  in  figures  400, 
401.     Note  protection  of  fingers  from  chafing  by  compress  cloth  and  bandaging  of  hand. 


be  extended  and  this  position  maintained  by  a  long  internal 
splint  (see  Fig.  400).  This  splint,  made  of  splint-wood,  should 
be  the  width  of  the  arm,  and  should  reach  from  the  anterior 
axillary  margin  to  the  tips  of  the  fingers.  This  is  well  padded 
with  sheet  wadding  at  the  bend  of  the  elbow  (see  Fig.  401).  The 
contiguous  skin  surfaces  of  the  fingers  are  protected  from  chafing 
by  strips  of  gauze  or  compress  cloth  placed  between  them,  and 


3i8 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


a  pad  is  put  in  the  palm  for  comfort  (see  Fig.  402).  The  splint 
is  held  in  position  by  four  straps  of  adhesive  plaster,  one  placed 
at  either  end  of  the  splint  and  one  above  and  below  the  elbow- 
joint.  The  upper  or  loose  fragment  is  pushed  down  toward  the 
shaft  of  the  ulna,  and  held  in  place  by  a  strap  of  adhesive  plaster 
carried  around  the  upper  side  of  the  olecranon  fragment  and 
fastened  to  the  splint  lower  down.     Sheet  wadding  and  gauze 


Ulna. 


Tip  of  ulnar 
styloid. 


Radius. 


Epiphyseal  line. 


Tip  of  radial 
styloid. 


Fig.  403. — Supination.     Compare  with  figure  406.    Note  the  relative  positions  of  styloid  pro- 
cesses  of  ulna  and  radius.     The  two  styloids  are  palpated  in  this  position. 


roller  bandages  applied  from  the  fingers  to  the  axilla  afford 
comfort  and  prevent  undue  swelling  of  the  hand.  Should  the 
separation  be  so  great  that  reduction  of  the  fragment  is  un- 
satisfactory, an  incision  and  suture  should  be  made  (see  Fig.  402). 
Treatment  if  the  Fracture  is  Open. — The  wound  should,  if 
necessary,  be  enlarged  to  permit  of  easy  inspection  of  the  joint 
surface.  The  joint  should  be  thoroughly  irrigated  with  boiled 
water.     The   wound   of    the   soft   parts,    enlarged   if    necessary, 


3^9 


320       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

should  be  very  thoroughly  cleansed  by  scrubbing  with  gauze 
wet  in  corrosive  sublimate  solution,  i  15000,  and  then  the  frag- 
ment of  the  olecranon  sutured  to  the  shaft. 

The  Operative  Treatment  of  Fresh  Fracture  of  the  Olecranon. — 
Considerable  disability  may  result  after  an  olecranon  fracture, 
especially  if  there  is  much  separation  of  the  fragments  and  if  the 
lateral  fascia  is  very  considerably  lacerated.  In  such  cases,  and 
in  cases  in  which  it  is  difficult  to  approximate  the  fragments, 
and  in  those  cases  in  which  associated  injuries  require  the  elbow 
to  be  placed  in  either  the  acutely  flexed  position  or  a  right-angled 
position,  immediate  suture  of  the  fracture  will  be  found  advan- 
tageous. 

If  the  fracture  is  an  open  one  the  compound  wound  can  be 
readily  utilized.  This  may  be  done  subcutaneously,  as  suggested 
by  Murphy.  In  subcutaneously  suturing  the  fragments  the 
wire  is  passed  through  the  shaft  of  the  ulna  and  the  olecranon 
fragment  or  tendon  of  the  triceps  by  being  carried  into  trans- 
verse drill  holes  which  were  placed  through  four  tiny  incisions 
to  the  bone  in  the  soft  parts.  The  wire  is  twisted  as  the  fragment 
approximates  to  the  shaft  and  is  cut  and  buried  beneath  the 
skin.  A  single  suture  closes  each  of  the  four  tiny  extra-articular 
incisions.  The  elbow  is  then  immobilized  as  usual.  Passive 
motion  should  be  begun  early  after  suture — as  early  as  the  end 
of  the  first  week — there  being  no  contra-indications  (other  com- 
plicating fracture,  very  great  joint  swelling,  or  great  damage  to 
the  soft  parts  about  the  elbow). 

The  After-care. — If  the  arm  has  been  put  up  temporarily  at  a 
right  angle  to  await  the  subsidence  of  the  swelHng,  gentle  mas- 
sage and  firm  bandaging  of  the  arm,  twice  daily,  until  the  swell- 
ing subsides  sufficiently  for  accurate  examination  and  a  more 
permanent  dressing,  will  be  of  very  great  service.  The  arm 
should  be  inspected  each  day  for  the  first  week.  Daily  massage 
should  be  continued  not  only  to  the  joint  region,  but  to  the 
forearm  and  upper  arm  as  well.  The  straps  and  bandages  should 
be  reapplied  as  they  become  too  tight  or  are  loosened  by  the 
disappearance  of  the  swelling.  After  about  two  weeks  the 
position  of  the  forearm  ma}'-  be  cautiously  changed.  The  small 
fragment  of  the  olecranon  should  be  held  fixed  during  the  ma- 


TREATMENT 


321 


nipulation.  If  the  arm  is  in  the  extended  position,  it  should 
be  gradually  flexed  some  five  or  ten  degrees,  and  returned  to  the 
extended  position.  If  the  arm  is  already  at  a  right  angle,  it 
should  be  gradually  extended,  at  first  a  few  degrees  only,  and 
returned  to  the  right-angle  position.  No  pain  should  be  ex- 
perienced by  the  passive  motion.  Painful  passive  motion  is 
harmful.  After  a  few  days  of  these  gentle  passive  motions  it 
will  be  wise  to  alter  the  angle  of  the  splint  so  that  the  arm  may 


Tip  of  styloid  of 
radius. 


Head  of  ulna. 


Fig.  405.— Pronation.     Compare  figure  407.     Note  that  palpating  fingers   feel  styloid  of  radius  and 

head  of  ulna. 


rest  in  the  changed  position  permanently.  After  about  four 
or  five  weeks  all  splints  should  be  omitted.  A  bandage  should 
be  worn  after  the  removal  of  the  spHnts  to  afford  support  to 
the  elbow. 

Union  of  the  fragments  usually  takes  place  in  from  three  to 
four  weeks.  After  six  weeks  to  three  months  the  movements 
of  the  elbow-joint  should  be  normal.  There  may  remain  as  a 
permanent  condition  slight  limitation  of  extension.     The  func- 


322 


FRACTURES  OF"  THE  BONES  OF  THE  FOREARM 


tional  usefulness  of  the  elbow  depends  more  upon  the  approxi- 
mation of  the  fragments  and  less  upon  the  kind  of  union  be- 
tween them.  The  union  between  the  fragments  is  more  often 
ligamentous  than  bony.  The  short  fibrous  union,  if  of  good 
width, — i.  e.,  if  it  covers  the  whole  of  the  broken  surface, — is  as 
efficient  as  a  bony  union.  A  ligamentous  union  accompanied 
by  great  disability  in  the  functional  usefulness  of  the  arm  should 
be  excised  and  the  bony  fragment  sutured  to  the  shaft.     Sutur- 


Fig.  406. — Method  of  examination  of 
wrist.  Note  supination  of  forearm  ;  posi- 
tion of  examining  hands  and  fingers ;  pal- 
pation of  the  styloid  process  of  the  radius 
and  the  head  of  the  ulna.  The  radial  sty- 
loid is  seen  to  be  lower  than  the  head  of 
the  ulna.     Compare  with  figure  403. 


Fig.  407. — Method  of  examination  of 
wrist.  Note  pronation  of  forearm ;  posi- 
tion of  examining  hands  and  fingers ;  pal- 
pation of  styloid  processes  of  radius  and 
ulna.  The  styloid  of  the  radius  is  lower 
than  the  styloid  of  the  ulna.  Compare 
with  figure  405. 


ing  of  the  periosteum  and  fibrous  tissue  about  the  fragments 
will  prove  fully  as  satisfactory  in  many  cases  as  suturing  the 
bone  with  silver  wire. 

Summary:  If  there  is  great  swelling,  delay  the  application  of 
the  permanent  splint.  Apply  internal  right-angle  splint.  Use 
compression  and  massage.  If  there  is  little  or  no  separation  of 
the   fragments,    use   a   right-angle   splint.     If   there   is   marked 


coLLEs'  fracture; 


323 


separation  of  fragments,  use  an  extended  position.  If  the  fracture 
is  open,  suture  the  fragments.  If  practicable,  at  the  outset, 
renew  the  bandage  and  massage  the  arm  twice  daily.  After 
two  weeks  cautious  passive  motion  should  be  made  daily.  After 
three  weeks  the  angle  of  the  splint  should  be  permanently  changed. 
After  four  weeks  all  splints  should  be  removed.  After  six  weeks 
to  three  months  a  useful  arm  should  result. 


Fig.  408. — Method  of  examination  in  a  case  of  injury  to  the  lower  end  of  the  radius.     Grasp- 
ing the  radius  above  and  below  the  probable  seat  of  fracture. 


Tetanus  is  rarely  seen  after  fracture  of  bone.  It  sometimes 
appears  after  open  fracture.  Early  amputation  and  the  admin- 
istration of  tetanus  antitoxin  are  the  most  rational  means  of 
treatment  in  these  cases. 


COLLES'  FRACTURE 

A  fracture  of  the  lower  end  of  the  radius  within  about  one 
inch  of  the  articular  surface  is  common  in  adults  and  is  unusual 
in  childhood.  A  fall  upon  the  outstretched  and  extended  hand 
is  the  most  frequent  cause.  With  the  introduction  of  the  gaso- 
line engine  a  new  cause  for  fracture  exists.  The  starting  of  a 
gasoHne  engine  by  turning  a  handle  connected  with  the  fly- 
wheel may  be  the  occasion  of  a  violent  twist  of  the  hand 
backward.     The    force    causes    a    clean,    transverse    fracture    of 


324 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


the  lower  end  of  the  radius,  close  to  the  joint,  and  without  im- 
paction. 

Anatomy. — In  a  case  of  traumatism  to  the  wrist  the  normal 
anatomical  relations  should  be  studied  upon  the  uninjured  wrist, 
and  then  a  careful  examination  made  of  the  injury.  The  normal 
wrist  should  be  looked  at  from  the  front  and  back  and  from  each 
side  with  the  hand  supinated.  Anteriorly,  the  base  of  the  thenar 
eminence  is  lower  than  that  of  the  hypothenar  eminence.     Pos- 


Fig.  409. — A  "  reversed  Colles'  "  frac- 
ture. Arrow  points  to  the  site  of  fracture. 
Note  the  displacement  of  the  upper  end 
of  the  lower  fragment  backward. 


Fig.  410. —  A  Colles'  fracture.  Injury  to  the 
styloid  process  of  the  ulna.  Arrows  point  to 
sites  of  fracttire.  Note  the  comminution  of  the 
radius. 


teriorly,  on  the  inner  side,  the  styloid  process  of  the  ulna  is  visible 
with  the  marked  depression  below  it.  Laterally,  on  the  radial 
side,  is  seen  the  curve  backward  on  the  anterior  surface  of  the 
radius  where  the  base  of  the  styloid  process  of  the  radius  joins 
the  shaft.  Laterally,  upon  the  ulnar  side,  are  seen  not  only  the 
styloid  of  the  ulna  and  its  associated  depression,  but  the  hollow 
above  the  prominence  of  the  hypothenar  eminence. 

The  normal  wrist  should  be  felt  with  the  hand  both  in  supina- 
tion and  pronation.  With  the  hand  supinated  (see  Fig.  406) 
the  tip  of  the  styloid  process  of  the  radius  is  found  to  be  lower 
(nearer  the  hand)  than  the  head  of  the  ulna.  With  the  hand 
in  pronation  (see  Fig.  407)  the  tip  of  the  styloid  process  of  the 
radius  is  found  to  be  a  little  lower  (nearer  the  hand)  than  the  tip 


COLLES     FRACTURE — ANATOMY 


325 


of  the  styloid  process  of  the  ulna.  To  ascertain  the  relative 
position  of  the  styloid  processes,  the  injured  wrist  should  be 
grasped  by  the  two  hands  and  the  styloids  felt  by  the  tips  of  the 


Fig.  411. — Colles' fracture.     Characteristic  appearance.     Note  backward  displacement  of  the 
hand  and  wrist.     Palmar  prominence. 


Fig.  412. — Colles'  fracture,  radial  side.    Marked  crease  at  base  of  thumb.    Dorsal  and  palmar 

prominences. 


Fig.  413. — Colles'  fracture,  ulnar  side.    Absence  of  ulna  on  the  dorsum  of  the  wrist ;  presence 
anteriorly.     Marked  crease  in  front  of  displaced  ulna.     Dorsal  prominence  marked. 


forefingers.  The  styloid  process  of  the  radius  and  the  shaft 
immediately  above  it  should  be  carefully  palpated  to  determine 
the  extreme  thinness  of  the  bone  above  the  thick  styloid  process 
(see  Fig.  408;.    The  width  of  the  wrist  between  the  styloid  pro- 


326 


FRACTURES  OF  THE)  BONES  OF  THE  FOREARM 


cesses  should  be  measured  by  means  of  a  tape,  or,  better,  by  a 
pair  of  calipers. 

The  movements  of  the  normal  wrist  and  forearm  should  be 
carefully  observed.  Pronation  and  supination  of  the  forearm 
and  flexion,  extension,  abduction,  and  adduction  of  the  hand 
should  be  carefully  performed.  These  simple  observations 
quickly  made  upon  the  normal  wrist  enable  one  to  establish  a 
standard  for  comparison  with  the  injured  wrist.  In  every  case 
in  which  there  is  a  question  of  fracture  the  examination  should 
be  made  by  means  of  an  anesthetic  (see  Fig.  408).    If  for  sufficient 


Fig.  414. —  Colles' 
fracture,  anterior  bulg- 
ing of  flexor  tendons ; 
absence  of  dorsal  prom- 
inence of  head  of  ulna. 


Fig.  415. — Colles'  fracture. 
The  dorsal  prominence  is  not 
uncommonly  seen  after  recov- 
ery from  fracture  of  the  radius 
when  the  displaced  bones  have 
been  but  partially  reduced. 
Slight  lateral  deformity. 


Fig.  416.— Colles'  fracture. 
Hand  carried  to  radial  side. 
Prominent  ulna  anteriorly. 
Thenar  eminence  lower  than 
normal. 


reason  complete  anesthesia  is  contraindicated,  primary  anesthesia 
will  prove  to  be  sufficient.  In  the  larger  proportions  of  cases 
of  Colles'  fracture  primary  anesthesia  will  be  satisfactory  for 
both  the  examination  and  the  first  dressing  of  the  fracture. 

Symptoms. — In  Colles'  fracture  the  wrist  appears  unnatural. 
The  thenar  eminence  of  the  thumb  is  higher,  nearer  to  the  wrist 
than  usual,    as   compared   with   the   hypothenar  eminence    (see 


COLIvES'    FRACTURE — SYMPTOMS 


327 


Fig.  416).  Anteroposterior  and  lateral  deformities  are  appar- 
ent to  a  greater  or  less  degree.  It  is  said  that  at  times 
an  anterior  displacement  of  the  lower  fragment  occurs,  the 
reverse  of  the  ordinary  displacement.  It  is  unusual  (see  Fig. 
409). 

The  anteroposterior  deformity  is  caused  by  the  projection 
of  the  lower  end  of  the  upper  fragment  into  the  palmar 
surface  of  the  wrist,  pushing  the  flexor  tendons  forward  (see 
Fig.  384),  and  by  the  projection  of  the  upper  end  of  the  lower 
fragment  toward  the  dorsal  surface  of  the  wrist,  pushing  the  ex- 
tensor tendons  backward.      Impaction  of  the  radial  fragments 


p;g_  417.— A  transverse  fracture  of  the  lower  end  of  the  radius,  with  a  crack  into  the  joint  and  fracture 
of  the  styloid  process  of  the  ulna.     Little  displacement.     See  a  T-fracture  into  wrist-joint. 

may  be  another  factor  in  the  production  of  the  deformity.  This 
deformity  is  spoken  of  by  the  older  writers  as  the  silver-fork 
deformity.     The  reason  is  obvious  (see  Figs.  411,  412,  413,  414, 

415)- 

The  lateral  deformity  (see  Fig.  416)  is  caused  by  several  factors: 

the  impaction  of  the  radial  fracture,  lateral  displacement  of  the 
lower  fragment,  and  by  rupture  of  the  inferior  radio-ulnar  liga- 
ments. The  abduction  of  the  whole  hand,  the  prominence 
laterally  of  the  lower  end  of  the  ulna,  the  disappearance  of  the 
ulnar  head  from  the  dorsum  of  the  wrist,  are  to  be  noted.  Be- 
cause  of  the   displacement   of  the   radial   lower   fragment,    the 


coLLEs'   fracture; — differe;ntial  diagnosis         329 

normal  relations  are  no  longer  maintained  between  the  styloid 
processes  of  the  radius  and  ulna.  There  is  a  reversal  of  relations. 
The  radial  styloid  is  higher  than  usual.  It  is  on  the  same  level 
with  or  higher  than  the  head  of  the  ulna. 


Fig.  420.— Lateral  view  of  Fig.  423-     Note  Fig.  421.— A    starting    of    the    lower    radial 

the  backward  displacement  of  the  lower  frag-  epiphysis.     No  great  displacement.      The   arrow 

ment.    Arrow  points  to  lower  fragment.    Double  points  to  the  epiphysis, 
arrows  point  to  the  sharp  lower  end  of  the  upper 
fragment. 


4 

\ 


Fig.  422. — Fracture  of  the  lower  end  of  the  Fig.  423. — A  transverse  fracture  of  the  radius 

radius  with  displacement  of  both  bones  toward  above  the  level  of  the  epiphyseal  line.     Note  the 

the  palmar  surface.     Arrow  points  to  the  frac-  impaction.     Arrow  points  to  fracture, 
ture. 


It  is  possible  to  have  present  a  fracture  of  the  lower  end  of  the 
radius  (a  Colles'  fracture)  without  any  appreciable  alteration 
in  the  levels  of  the  styloid  processes.  The  existence  of  the 
normal  relations  of  the  styloids  does  not  preclude  the  presence 
of  a  fracture. 

Direct  pressure  over  the  broken  bones  elicits  pain,  but  crepitus 


330 


FRACTURES  OF  THK  BONES  OF  THE  FOREARM 


is  often  undetected  until  the  patient  is  examined  with  the  aid  of 
an  anesthetic.  A  transverse  ridge  is  sometimes  present  on  the 
posterior  and  external  surface  of  the  radius,  corresponding  to  the 
line  of  fracture.     In  certain  cases  of  Colles'  fracture  the  wrist 


Fig.  424. — Fracture  of  the  lower  end  of  the  radius,  lateral  view.     Xote  impaction;  deformity. 


Fig.  425. — Fracture  of  the  lower  end  of  the  radius,  anteroposterior  view.    Note  impaction;  displacement 

of  the  hand. 


may  not  appear  very  unnatural.  There  may  be  scarcely  any 
deformity.  The  normal  relation  may  be  nearly  preserved.  If 
there  is  little  displacement  of  the  fragments,  it  may  be  difficult 
to  determine  the  existence  of  fracture.  An  appreciation  of  slight 
differences   from    the   normal   will,    under    these   circumstances, 


Fig.  426. — Transverse  fracture  of  the  lower  end  of  the  radius.     Compare  Fig.  428.     Arrow  marks 

fracture. 


Figv  427 — A  comminuted  slightly  impacted  fracture  of  the  lower  end  of  the  radius  and  fracture  of  the 
styloid  of  the  ulna.     Arrows  point  to  seats  of  fracture. 


tig.  428. — Lateral  view  of  Fig.  426.      \ote  the  thickening  due  to  impaction  of  the  radius.     Note  also 
the  beginning  backward  disijhucmcnt  of  the  lower  fragment.     Arrow  pomts  to  fragment. 


Fig.  429. — A  lateral  view  of  the  fracture  of  the  lower  end  of  the  radius.  Note  the  characteristic 
backward  displacement  of  the  lower  fragment  and  the  forward  displacement  of  the  lower  end  of  the 
upper  fragment.     Arrow  points  to  the  latter. 


Fig.  430. — An  impacted  fracture  of  the  lower  end  of  the  radius.     Xote  the  line  of  the  cortical  shaft  and 
the  upward  displacement  of  the  lower  fragment. 


Fig.  431. — Fracture  longitudinal  of  the  inner  side  of  the  lower  end  of  the  radius  into  the  joint.     The 
arrow  points  to  the  line  of  fracture.    The  ulnar  styloid  is  fractured. 


Fig.  432. — Fracture  of  the  styloid  process  of  the  radius  into  the  middle  of  the  Joint  surface.  Arrow 
points  to  the  beginning  of  the  fracture  line  in  the  process.  A  continuation  of  the  arrow  indicates  ths 
direction  of  the  line  of  fracture. 


Fig.  4.1.3- — Comminuted  fracture  of  the  lower  end  of  the  radius.     Note  the  outvvard  displacement  of  the 
Styloid  of  the  radius  and  the  comminution  of  the  articular  surface  of  the  lower  end  of  the  radius. 

333 


Fig.  434. — Comminuted  fracture  of  the  lower  articular  end  of  the  radius.     See  Fig.  435.     A,  T-frac« 

ture  into  wrist-joint. 


Fig-  435- — Lateral  ^^ew  of  Fig.  434.    Xote  the  displacement  of  the  lower  fragment  backward,  carrying 

with  it  the  hand. 


Fig.  436. — Lateral  view  of  a  Colles'  fracture.     Note  the  anterior  displacement  of  a  portion  of  the 
fracture  fragments.     The  arrow  points  to  the  fragment. 

334 


COLLES'    FRACTURE — DIFFERENTIAL    DIAGNOSIS 


335 


prove  of  great  value.     The  Rontgen  ray  will  be  of  service  in  this 
connection. 

After  injury  to  the  wrist  one  must  consider  in  the  differential 
diagnosis — 

A  sprain  of  the  wrist,  Fracture  of  the  shaft  of  one  or  both  bones 

Contusion  of  the  bones  near  the  wrist,  low  down 

Dislocation  of  the  wrist  backward.  Separation  of  the  lower  radial  epiphysis. 

A  sprain  of  the  wrist  is  rather  unusual.     There  very  often 
exists  in  so-called  sprains  a  definite  anatomical  lesion  of  bone. 


Fig.  437. — Fracture  of  inner  edge  of  the  radius  (X-ray  tracing). 


Fig.  438.— Fracture  of  radial  styloid  (Massachusetts  General  Hospital,  1252.    X-ray  tracing). 


The  deformity  due  to  the  distention  of  the  synovial  sac  with 
fluid  is  conspicuous  over  the  back  of  the  wrist-joint  and,  there- 
fore,  near  the  hand.     There  is  tenderness  upon  pressure  over 


336 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


the  synovial  membrane  anteroposteriorly.  There  is  Httle  or  no 
tenderness  over  the  radius  upon  deep  pressure.  There  is  an 
absence  of  the  positive  signs  of  fracture.  It  is  not  an  uncommon 
experience  to  find  an  injury  to  the  lower  end  of  the  radius  pre- 
senting no  positive  fracture  signs,  which  is  proved  by  the  Rontgen 


Fig.  439. — Fracture  of  both  bones  near  wrist.    Note  deformity  away  from  (above)  wrist-joint 

(after  Helferich). 


Fig.  /)4o. — Fracture  of  the  lower  end  of  the  radius.    Lateral  view.    Note  silver-fork  deform- 
ity.   Deformity  (above)  near  wrist-joint  (after  Helferich). 


ray  to  be  a  break  of  the  lower  end  of  the  radius.  Many 
of  these  obscure  lesions  are  passed  over  as  sprains  of  the 
wrist.  Any  injury  to  the  wrist,  no  matter  how  trivial,  should 
be  regarded  with  suspicion  until  there  is  absolute  proof  that 
fracture  is  absent. 

A  Contusion  of  One  or  Both  Bones  near  the  Wrist- joint :  Tender- 


COLLKS'    FRACTURE- 


DIFFERENTIAI.    DIAGNOSIS  337 

The  Rontgen 


ness  is  localized.     Fracture  signs  are  all  absent 
ray  will  assist  in  determining  this  diagnosis. 

Dislocation  of  the  wrist  backward  is  rare.  The  posterior 
prominence  is  lower  down  on  the  wrist  than  in  Colles'  fracture. 
The  upper  surface   of  the  displaced  carpus  can   be  felt.     The 


Fig.  441  —Fracture  of  the  lower  end  of  the  radius  into  the  wrist-joint.     Fracture  of  the  styloid 
of  the  ulna.     Note  comminution  of  lower  fragment  of  radius. 


Radial  epiphysis,  outer 
fragment. 


// 


Radial  epiphysis,  inner 

fragment. 
Displaced   styloid  pro- 
cess of  ulna. 
Ulnar  epiphyseal  line. 


Fig.  442. 


-Fracture  of  the  epiphysis  of  the  lower  end  of  the  radius  and  of  the  styloid  process 
of  ulna  (Massachusetts  General  Hospital,  712.     X-ray  tracing). 


relation  of  the  two  styloids  is  preserved.  The  deformity  dis- 
appears and  does  not  tend  to  reappear  when  traction  is  made 
on  the  hand  and  pressure  is  made  over  the  dorsal  prominence. 
Fracture  of  the  shaft  of  one  or  both  bones  low  down  may 
simulate  the  anteroposterior  deformity  of   Colles'  fracture,  but 


Fig. 


443- — Case:  Adult.     Very  great  comminution  of   lower  end  of   the  radius.     Extremely 
difficult  to  mold  fragments  into  good  positions.     Note  abduction  of  hand. 


338 


COIvIvKS'    FRACTURE^ASSOCIATED    LESIONS 


339 


an  absence  of  other  positive  signs  is  important.  The  Rontgen 
ray  determines  the  exact  seat  of  the  lesion.  Abnormal  mobility 
and  crepitus  are  readily  obtained  without  the  administration  of 
an  anesthetic. 

A  Separation    of  the   Lower   Epiphysis   of   the   Radius:   The 
lower  epiphysis  of  the  radius  unites  with  the  shaft  about  the 


'Fig.  i;44. — Dorsal  dislocation  of  the  wrist.     Note  deformity  at  wrist-joint  neither  above  nor 
below  it  (after  Helferich). 


Fig.  445. — Dorsal  dislocation  of  the  hand  at  carpometacarpal  joints.    Note  deformity  below 
wrist  (after  Helferich). 


twentieth  year.  The  radius  increases  in  length  chiefly  through 
growth  from  its  lower  epiphysis.  This  lesion  occurs  much  more 
commonly  than  has  hitherto  been  supposed.  It  is  usually  classed 
as  a  Colles'  fracture,  no  very  careful  examination  being  made. 
The  displacement  of  the  epiphysis  is  backward,  but  it  is  not 
sufficient  to  carry  the  fragment  off  and  out  of  contact  with  the 


340 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


diaphysis.  In  Colles'  fracture  the  dorsal  swelling  is  most  in 
evidence.  In  a  separation  of  the  lower  radial  epiphysis  the 
palmar  swelling  is  greatest.  The  lateral  deformity  of  the  wrist 
is  usually  absent  in  epiphyseal  separations.  There  is  often 
less  deformity  than  is  found  in  most  Colles'  fractures,  and  it  is 
nearer  the  hand.     The  crepitus  is  soft  and  cartilaginous,   and 


Fig.  446 — Reduction  of  Colles'  fracture.     Note  position  of  hands  in  forcibly  hyperextending 
the  lower  fragment ;  breaking  up  impaction. 


Fig.  447.. — Reduction  of  Colles'  fracture.     Note  grasp  upon  forearm  and  the  lower  fragment  of 
the  radius,  traction  and  countertraction  being  made;  breaking  up  the  impaction. 


easily  obtained  without  an  anesthetic.  Pain  is  present  as  well' 
as  tenderness  to  pressure  over  the  epiphyseal  line.  There  is- 
often  swelling  along  the  dorsum  of  the  wrist  corresponding  to 
the  area  of  detached  periosteum.  Union  is  rapid  and  complete. 
There  is  almost  never  any  arrest  of  growth  following  this  injury. 
The   treatment   of  separation   of  the   lower   radial  epiphysis  is- 


COLIyES'    FRACTURE — TREATMENT 


341 


similar  to  that  of  a  Colles'  fracture.  A  fracture  of  the  lower 
radial  epiphysis  is  occasionally  seen  ;  it  is,  however,  a  rare  lesion 
(see  Fig.  442). 

Associated  with  every  Colles'  fracture  there  may  be  one  or 
more  of  the  following  lesions  :  A  fracture  through  the  lower 
end  of  the  ulna,  which  is  rather  rare.  A  fracture  of  the  sty- 
loid process  of  the  ulna,  which  occurs  in  about  fifty  to  sixty- 
five  per  cent,  of  all  cases  (see  Fig.  427).  A  rupture  of  the 
interarticular  triangular  fibrocartilage  at  its  insertion  into  the 
base  of  the  styloid  process  of  the  ulna.  This  is  probably  quite 
common,  and  accounts  in  part  for  the  broadening  of  the  wrist- 
joint.     A  perforation  of  the  skin  by  the  lower  end  of  either  the 


Fig.  448. — Reduction  of  Colles'  fracture.  Note  position  of  the  thumbs  and  fingers. 
Lower  fragment  is  pushed  into  place  while  counterpressure  is  made  by  the  fingers  upon  the 
upper  fragment. 


ulna  or  the  shaft  of  the  radius,  making  an  open  fracture.  A 
fracture  of  the  scaphoid  bone,  although  occurring  often  alone, 
is  not  very  uncommonly  associated  with  Colles'  fracture.  A 
sprain  of  the  hand,  wrist,  forearm,  elbow,  or  shoulder  may  occur. 
It  is  wise  to  examine  the  whole  upper  extremity,  particularly 
a  few  days  after  the  accident,  as  it  is  at  this  time  that  sprains 
associated  with  fracture  are  likely  to  be  detected. 

Treatment. — The  ordinary  uncomplicated  fracture  is  here 
under  consideration.  Reduction  should  be  accomplished  as 
soon  as  possible.  Complete  reduction  can  not  be  made  satis- 
factorily without  the  administration  of  an  anesthetic,  either 
to  complete  or  partial  anesthesia.  Very  great  force  is  needed 
to   accomplish   satisfactory   reduction  of   impacted  fractures  of 


342 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


the  radius.  It  is  because  of  the  use  of  too  httle  force  that  often 
a  sHght  bony  deformity  remains  after  union  has  taken  place. 
A  Method  of  Reduction. — Grasp  with  the  thumbs  and  fore- 
fingers of  the  two  hands  the  upper  and  lower  fragments.  Free 
the  lower  fragment  completely  from  the  upper  by  pressure  and 


I'lg-  449- — Fracture  ol  radius  iK-ar  wrist.     Method  of  applying  the  posterior  splint  and  dorsal 
pad  in  displacement  of  lower  fragment  backward. 


Fig.  450. — Fracture  of  radius  near  wrist.  Method  of  applying  anterior  splint  and  pad 
and  of  holding  the  two  splints  and  arm  for  the  application  of  straps.  Anterior  splint  is  cut 
out  below  the  thenar  eminence. 


traction  backward  and  forward  and  laterally  upon  the  lower 
fragment,  using  all  the  force  that  is  needed  (see  Figs.  446,  447). 
The  lower  fragment  may  then  be  forced  into  position  by  pressure 
of  the  two  thumbs  upon  the  dorsum  of  the  wrist  (see  Fig.  448)- 
When  reduction  is  completed,  the  hand  should  be  allowed  to  rest 


coivLEs'  fracture; — treatment. 


343 


naturally  without  support  to  determine  whether  there  is  a  re- 
currence of  the  deformity.  If  there  is  no  recurrence  of  the 
deformity,  the  fracture  may  be  fixed.  If  there  is  recurrence  of 
the  deformity,  notice  should  be  taken  of  the  direction  of  the 
displacement  of  the  lower  fragment,  that  proper  pads  may  be 
applied  to  hold  it  in  position.  A  pad  of  compress  cloth  placed 
on  the  dorsum  of  the  wrist  over  the  lower  fragment  will  easily 


Fig.  451. — Fracture  of  the  forearm  near  the  wrist-joint.  Anterior  and  posterior  splints. 
Straps  are  taut.  Note  length  of  splints,  the  position  of  the  three  straps,  and  the  cutting  out 
of  the  anterior  splint  to  clear  the  thenar  eminence. 


Fig.  452. — Fracture  of  the  forearm  near  the  wrist-joint.  Notice  wrinkles  in  the  straps. 
The  straps  are  loose  from  the  pressure  of  the  two  splints  together.  Thus  is  illustrated  the 
fact  that  the  straps  should  retain  splints  in  position  without  exerting  much  pressure. 


hold  it  if  ordinarily  displaced.  A  knowledge  of  the  direction 
of  the  displacement  of  the  lower  fragment  will  suggest  the  pre- 
vention of  the  recurrence  of  the  deformity.  The  Rontgen  ray 
is  making  possible  a  more  intelligent  treatment  of  this  fracture 
of  the  radius.  The  bone  is  so  nearly  subcutaneous  that  one 
can  take  advantage  of  an  accurate  knowledge  of  the  line  or  lines 
of   fracture   in    attempting   reduction    of   the    malposition.     In- 


344 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


telligently  applied  force  can  now  be  used  in  each  fracture  instead 
of  the  hitherto  bhnd  routine  manipulation.  Thus,  less  injury 
is  done  in  setting  the  fracture,  and  better  anatomical  results 
are  obtained. 


Fig.  453- — Posterior  splint  padded  with  two  thicknesses  of   sheet  wadding.     Two   straps. 
Note  length  of  splint  and  position  of  straps. 


Fig.  454- — Posterior  splint,  three  straps,  and  pad  at  the  seat  of  fracture.     Note  comfortable 
position  of  forearm  and  hand. 


Fig.  455  — Completed   dressing,    similar  to  figures  453,  454.     The  bandage  is  applied  evenly  and 

uniformly. 


It  is  well  to  restore,  if  possible,  the  prominence  of  the  lower 
end  of  the  ulna  at  the  back  of  the  wrist.  Usually,  after  a  Colles' 
fracture  has  healed  and  functional  usefulness  exists  in  the  wrist 
and  hand,  the  ulna  will  be  found  to  have  slumped  forward — to 
have  disappeared  from  the  dorsum  of  the  wrist.     This  can  be 


COIvIvES'    FRACTURE — TREATMENT 


345 


prevented  partially  at  the  time  of  setting  the  fracture,  by  padding 
the  ulna  anteriorly  and  by  completely  correcting  the  radial 
deformity  and  strongly  adducting  the  hand. 

Retentive  Apparatus. — The  simplest  splint  is  the  best.  If  there 
is  considerable  swelling  about  the  seat  of  fracture  in  a  rather 
muscular  and  large  arm,  it  is  best  to  use  the  following  apparatus : 
Two  pieces  of  splint-wood,  one  for  the  back  and  the  other  for 
the  front  of  the  forearm,  are  provided.  The  back  or  posterior 
splint  should  extend  from  the  heads  of  the  metacarpal  bones  to 


JplMM^i. 


y^ 


I  J'  -.I 


Fig.  456. — To  illustrate  ulna  cul  out  on  the  dorsal  splint  for  Colles'  fracture  of  the  right  wrist. 

a  little  above  the  middle  of  the  forearm  (see  Fig.  449).  At  the 
spot  where  the  lower  end  of  the  ulna  touches  the  dorsal  splint 
a  piece  should  be  cut  out  from  the  splint  (see  Fig.  456)-     If  this 


Fig.  457- — Hand  and  fingers  extended.  Dorsal  surface  of  forearm  and  hand  practically 
straight  and  in  the  same  plane.  The  anterior  surface  of  the  forearm  and  hand  are  rounded 
and  irregular  surfaces. 


is  done  there  will  be  no  undue  pressure  forward  upon  the  lower 
end  of  the  ulna  (Pool)  and  the  likelihood  of  an  absence  of  ulnar 
prominence  upon  the  back  of  the  wrist  will  be  lessened.  The 
front  or  anterior  splint  should  extend  from  the  heads  of  the 
metacarpal  bones  to  a  little  above  the  middle  of  the  forearm 
(see  Fig.  451).  These  splints  are  padded  evenly  and  smoothly 
with  sheet  wadding,  retentive  pads  at  the   seat  of  the  fracture 


346     FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

being  used  as  needed.  The  hand  and  forearm  are  held  in  semi- 
pronation.  The  hand  is  adducted.  The  dorsal  splint  is  applied 
and  held  in  position.     The  anterior   splint  is  then  applied  with 


Fig.  45S. — Forearm,  ulnar   side;    partial    pronation.     Xote  normal  prominence  of   head  of  ulna 
(Pool). 

the  pads,  and  all  are  held  in  position  by  adhesive-plaster  straps. 
The  arm  and  splints  are  covered  with  a  bandage.  Direct  pressure 
should  be  aA^oided  over  the  head  and  styloid  process  of  the  ulna 


Fig.  459- — Radial  side  of  forearm  with  anteroposterior  plaster  splints  applied.  Roll  supporting 
fingers  ;  straight  wooden  splint  upon  anterior  plaster  splLat  for  greater  support.  Small  block  of  wood 
anterior  to  the  lower  end  of  the  radius  (after  Pool). 

posteriorly,  in  order  to  minimize  the  disappearance  of  the  bone 
from  the  dorsum  of  the  wrist.  A  pad  placed  anteriorly  and  lat- 
erally over  the  lower  end  of  the  ulna  is  often  useful  in  reducing 


Fig.  460. — Dorsal  splint  of  plaster-of-Paris  showing  ulnar  cut-out  (after  Pool). 

the  ulnar  head  and  styloid.  The  adhesive-plaster  straps  should 
be  snugly  but  loosely  applied.  They  are  intended  simply  to 
retain   the    splints   in  position    (see  Fig.   451).     After  their  ap- 


COLIvES'  FRACTURE — TREATMENT  347 

plication,  pressing  the  two  splints  together  should  show  that 
there  is  considerable  slack  in  the  straps  (see  Fig.  452; ;  a  springi- 
ness should  exist  between  the  splints.  The  necessary  pressure 
on  the  splints  should  be  secured  by  the  bandage.  The  fingers 
are  allowed  to  be  free  and  movable.  The  arm  is  held  in  a  sling. 
The  sling  should  be  so  adjusted  as  to  receive  the  whole  weight 
of  the  arm,  the  hand  lying  free  from  the  upward  pressure  of  the 
sling.  The  sling  should  be  applied  with  the  ends  crossed  in 
frorit  of  the  neck. 

At  the  end  of  the  first  week  in  most  cases,  in  place  of  the  two 
anteroposterior  splints,  it  will  be  wise  to  use  one  posterior  splint 
only  and  an  anterior  pad  over  the  seat  of  fracture.  The  pos- 
terior splint  is  applied  evenly  padded,  and  if  necessary,  a  small 
pad  is  placed  over  the  dorsum  of  the  lower  fragment.  The 
splint  is  held  in  place  by  two  adhesive-plaster  straps — one  at  the 


Points  to  seat  of  fracture. 
Fig.  461. — Anterior  and  posterior  splints.     Note  how  naturally  the  dorsum  of  forearm  and  hand 
rest  upon  straight  splint.     Note  pad  necessary  to  fill  the  normal  arch  of  radius.     The  strap  at  the 
wrist  is  purposely  omitted  so  as  not  to  obsciure  the  bone. 

upper  end  of  the  splint  around  the  forearm,  the  other  around 
the  metacarpal  bones  at  the  lower  end  of  the  splint  (see  Fig. 
453).  The  fracture  should  be  held  securely  by  a  third  strip  of 
adhesive  plaster  at  the  seat  of  fracture  over  a  compress-cloth 
pad,  which  fills  up  the  anterior  hollow  of  the  radius  (see  Figs. 
454,  461).  This  pad  holds  the  fragments  securely.  A  roller 
bandage  gives  even  compression  and  support  to  the  whole  arm 
(see  Fig.  455)- 

The  posterior  surfaces  of  the  forearm,  wrist,  and  hand  in  the 
extended  position  are  practically  in  one  plane  (see  Fig.  457)  ; 
hence,  the  reasonableness  of  the  use  of  the  posterior  splint.  The 
arm  lies  naturally  upon  it.  The  anterior  surface  only  requires 
accurate  padding.  The  difficulty  in  applying  an  anterior  splint 
accurately  to   the  forearm  and   wrist  is   rendered  clear  by  the 


348 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


illustration.  The  front  of  the  forearm  and  wrist  is  a  rounded  and 
uneven  surface.  In  order  accurately  to  control  the  bone  by  a 
splint  applied  to  the  anterior  surface  of  the  forearm,  the  padding 
must  be  applied  with  greater  care  than  is  ordinarily  exercised. 
No  splint  is  manufactured  that  fits  the  wrist  accurately.  If  the 
surgeon  depends  upon  manufactured  and  molded  splints,  he  is  in 
very  great  danger  of  neglecting  the  fracture.  It  is  best  for  the 
surgeon  to  use  simple  splints,  and  to  hold  the  fracture  reduced 
by  personally  applied  pads  and  straps. 


Fig.  462. — CoUes'  fracture.     Position  of  short  dorsal  splint  of  wood  and  palmar  pad  of  com- 
press cloth.     Note  method  of  holding  before  the  application  of  the  strap. 


Fig.  463. — Colles'  fracture.     Short  dorsal  splint  and  palmar  pad  held  in  position  by  adhesive- 
plaster  strap. 


Until  the  time  of  union  the  arm  should  always  be  comfort- 
able. The  patient  should  be  seen,  if  convenient,  within  the  first 
twenty-four  hours  of  the  application  of  the  splint.  Swelling 
may  occur  after  the  splints  are  applied,  causing  blueness  or 
swelling  of  the  fingers.  The  bandage  may  need  reapplying  to 
relieve  this  increase  of  pressure.  With  the  subsidence  of  the 
primary  swelling  the  bandage  naturally  loosens  and  will  require 
tightening.     It  is  rare  that  the  straps  and  padding  will  need 


COLLES'  FRACTURE — TREATMENT 


349 


more  than  slight  readjustment  during  the  first  week  of  treatment. 
At  least  every  three  days  the  pads  should  be  removed  with  great 
care,  and  the  arm  carefully  inspected.  The  alinement  of  the 
fragments  is  maintained  by  readjustment  of  the  pads. 


Fig.  464. — Colles'  fracture.  Cravat 
sling  holding-  wrist  improperly.  Hand 
pronated. 


Fig.  465. — Colles'  fracture.  Cravat 
sling  holding  wrist  properly.  Hand  semi- 
supinated.  Wrist  resting  upon  ulnar  side 
with  hand  unsupported. 


Fig.  466.— Right  Colles'  fracture  in  an  old  woman.  Splints  ajiiilied  for  five  weeks  with- 
out removal.  Note  deformity  and  flattening  of  hand  and  forearm.  The  fingers  and  wrist 
are  stiff  and  swollen.     Left  hand  is  normal. 


Gentle  massage  should  be  instituted  to  the  fingers,  hand,  wrist, 
and  forearm  during  the  second  week.  Passive  and  active  move- 
ments of  the  fingers  and  wrist  are  to  be  made  through  the  second 


350       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

week.  During  the  second  or  third  week  it  will  be  possible  to 
shorten  the  dorsal  splint  and  also  to  increase  the  amount  of  passive 
and  active  motion.  At  the  end  of  the  second  or  third  week 
the  union  will  be  found  to  be  firm.  During  the  third  or  fourth 
week  the  splint  may  be  removed  and  the  wrist  be  supported  by  a 
wooden  dorsal  pad  (see  Figs.  462,  463)  two  inches  long  and  the 
width  of  the  wrist,  and  by  a  palmar  radial  pad  of  compress  cloth 
and  strips  of  adhesive  plaster  about  two  inches  wide.  The 
middle  of  the  plaster  should  come  at  the  line  of  the  break  in  the 
bone.  After  the  fourth  week  all  padding  may  be  removed,  and 
the  wrist  supported  by  a  simple  bandage.  The  fingers  and 
hand  may  be  used  at  this  time.  After  the  removal  of  the  splint 
and  while  the  arm  is  carried  in  a  sling  great  care  must  be  ex- 
ercised lest  lateral  deformity  result  through  an  improper  adjust- 
ment of  the  sling  (see  Fig.  464).  The  forearm  should  rest  in  the 
sling  upon  the  ulnar  side,  and  the  hand,  being  unsupported,  should 
be  slightly  adducted  (see  Fig.  465). 

The  treatment  of  a  "  reversed  Colles'  "  fracture  (see  Fig.  409) 
will  differ  from  the  treatment  of  the  ordinary  fracture  only  in 
the  method  of  reduction  and  in  the  position,  of  the  retaining  pads. 
An  anterior  (palmar)  pad  will  be  needed  over  the  lower  frag- 
ment and  a  posterior  (dorsal)  pad  over  the  shaft  of  the  radius. 

Prognosis  and  Result. — The  swelling  about  the  fracture  in 
elderly  people  will  persist  longer  than  in  the  young.  A  func- 
tionally useful  wrist-joint  and  hand  should  follow  a  simple  un- 
complicated Colles'  fracture  in  healthy  young  adults.  For 
some  weeks  tenderness  ma}'  exist  over  the  styloid  of  the  ulna. 
Limitation  of  pronation  and  supination  may  persist  for  some 
time,  disappearing,  after  several  months,  more  or  less  com- 
pletely. Supination  is  the  last  movement  to  be  recovered. 
Limitation  of  movement  at  the  wrist  and  in  the  fingers  is  not 
incompatible  with  a  useful  wrist-joint.  Bony  union  is  rapid — 
within  three  weeks.  Care  must  be  exercised  lest  in  the  early 
removal  of  support  the  soft  callus  is  molded,  by  the  ordinary 
movements  of  the  wrists  and  hand,  into  some  permanent  de- 
formity. 

It  is  not  uncommon  for  the  line  of  the  fracture  of  the  lower 
end  of  the  radius  to  extend  into  and  involve  the  sigmoid  cavity 


OLD  FRACTURES  AT  LOWER  END  OF  RADIUS        35 1 

of  the  radius.  Thus  the  inferior  radioulnar  joint  is  involved 
in  the  fracture.  This  fact  is  of  importance,  as  it  helps  to  explain 
the  limitation  of  motion  in  pronation  and  supination  which  so 
often  exists  after  fracture  of  the  lower  end  of  the  radius.  Often 
perfect  supination  is  the  last  movement  to  be  recovered,  and 
this  may  in  part  be  explained  by  the  involvement  of  the  inferior 
radio-ulnar  joint. 

The  destruction  of  parts  of  the  lower  fragment  of  the  radius 
may  have  been  so  complete  that  it  is  impossible  to  restore 
the  wrist  to  its  normal  shape,  and  some  bony  deformity  will 
remain  permanently  (see  Fig.  443)-  Bony  deformity  is  not  in- 
compatible with  a  functionally  useful  arm.  In  many  instances 
it  is  impossible  wholly  to  prevent  a  slumping  forward  of  the 
head  of  the  ulna  and  its  corresponding  disappearance  from  the 
back  of  the  wrist.  Complete  reduction  of  the  radial  deformity 
together  with  a  frequently  re-adjusted  pad  upon  the  palmar 
surface  of  the  wrist  over  the  slumping  ulna-head  are  the  best 
methods  for  preventing  the  disappearance  of  the  ulna  from  the 
dorsum  of  the  wrist.  The  "ulnar  cut-out"  from  the  dorsal 
splint  should  be  employed  (see  p.  346,  Fig.  460).  Some  sHght 
widening  of  the  wrist  will  remain  after  most  Colles'  fractures. 
The  changes  in  the  tendon  sheaths  about  the  fracture,  the  periar- 
ticular adhesions  that  form,  especially  in  elderly  people,  cause 
much  more  hindrance  to  recovery  of  function  than  do  the  bony 
alterations  (see  Fig.  466).  Early  and  persistent  massage  and 
passive  motion  will  prevent  these  changes  from  becoming  per- 
manently troublesome.  Old  people  are  liable  to  have  considerable 
difficulty  in  regaining  the  movements  of  the  fingers,  on  account 
of  adhesions  within  and  without  the  tendon  sheaths.  The  con- 
tinued use  of  the  hot-air  treatment  is  of  value  in  restoring  mobility 
to  the  wrist  and  fingers.  The  more  nearly  the  deformity  in  Colles' 
fracture  is  corrected  at  the  first  setting,  the  milder  will  be  the 
subsequent  pain  about  the  wrist. 

Old  Fractures  at  the  Lower  End  of  the  Radius  (Colles' 
Fracture). — Colles'  fractures  showing  bony  union  with  marked 
deformity  should  be  corrected  by  operation,  especially  if  the 
wrist  is  functionally  impaired.  Colles'  fractures  two  or  three 
weeks  old  may  be  refractured  manually,  if  necessary,  to  correct 


Fig.  467. — Fracture  of  the  lower  end  of  the  radius  (Colles'  fracture).  Operation  for  correction 
of  the  deformity.  The  skin  incision  exposes  the  radial  nerve,  the  extensors  of  the  thumb  and  wrist. 
More  anteriorly  may  be  seen  the  radial  artery. 


Fig.  46S. — Fracture  of  the  lower  end  of  the  radius  (Colles'  fracture).  Operation  for  correction  of 
deformity.  Note  place  of  incision — line  of  fracture-deformity,  distal  fragment  displaced  backward, 
proximal  fragment  displaced  forward  ;  the  radial  nerve  with  the  extensors  of  the  -svTist  are  retracted 
backward,  the  extensors  of  the  thumb  are  retracted  forward  ;  the  insertion  of  the  supinator  is  exposed, 
beneath  which  lies  the  line  of  fracture. 

352 


OIvD    FRACTURES    AT    LOWER    END    OF    RADIUS  353 

existing  deformity.  The  ease  of  refracture  and  the  Hmits  in  time 
within  which  it  is  possible  will  vary  with  individual  cases. 

In  a  recent  case  in  a  young  adult  the  deformity  can  be  corrected 
and   the   function   improved   by   operative   interference. 

In  an  old  fracture  (three  to  six  months  or  older)  the  antero- 
posterior deformity  can  be  corrected;  usually  not  the  lateral  de- 
formity, and  the  pain  relieved ,  but  the  function  of  the  part  can- 
not ordinarily  be  very  much  improved.  The  difficulties  in  each 
individual  case  and  the  likelihood  of  improving  the  appear- 
ance of  the  wrist  or  its  function  should  be  carefully  considered 
before  operating. 

Method  of  Operating. — Lothrop's  Technique. — Accurate  under- 
standing of  the  displacement  (an  X-ray) ;  ether  anesthesia ;  careful 
preparation  of  the  skin  of  the  forearm  and  hand;  the  patient's 
hand  covered  with  a  sterile  rubber  glove;  a  tourniquet  applied 
over  a  folded  towel  just  below  the  elbow,  these  are  essential 
preparations  for  a  satisfactory  operation.  With  practice  the 
tourniquet  may  be  dispensed  with.  Rest  the  forearm,  the  hand 
of  which  is  held  semi-pronated  by  an  assistant,  on  a  table.  Make 
an  incision  on  the  external  surface  of  the  wrist  about  one  and  a 
half  to  two  inches  long,  the  center  of  which  is  over  the  fracture 
(see  Fig.  468).  A  radial  vein  may  be  encountered  which  may  be 
Ugated  or  drawn  to  one  side.  Expose  the  tendons  of  the  extensor 
brevis  pollicis  and  supinator  longus  muscles.  Approach  the 
line  of  fracture  in  front  of  and  behind  these  tendons  without 
disturbing  them  much.  No  other  tendons  need  be  encountered 
or  at  least  much  disturbed.  Expose  the  fracture,  using  small 
periosteum  elevators.  Keep  close  to  the  bone  and  expose  the 
Hne  of  fracture  for  the  full  width  of  the  radius  front  and  back, 
reaching  nearly  to  the  radio-ulnar  articulation.  This  is  done 
with  the  retractors  pushing  the  soft  parts  away  from  the  bone 
without  opening  any  tendon  sheaths.  By  means  of  a  small  bone 
drill,  numerous  perforations  are  made  in  the  line  of  union  so  as 
almost  to  sever  the  lower  fragment.  The  separation  is  then 
completed  by  means  of  small  chisels.  The  retractors  guard  the 
soft  parts  against  injury.  Gentle  force  is  used  so  as  to  entirely 
free  the  lower  fragment.     It  will  be  possible  now  to  correct  the 

backward  and  forward  displacement.     Sometimes  the  position  is 
23 


354     FRACTURES  OF  THE  BONKS  OF  THE  FOREARM 

made  more  satisfactory  if  the  projecting  anterior  border  of  the 
lower  end  of  the  upper  fragment  is  removed  with  narrow-bladed 
rongeur  forceps. 

The  prominent  ulna  is  an  unsightly  deformity.  A  shortening 
of  the  ulna  will  permit  of  accurate  apposition  of  the  radial  frag- 
ments and  will  probably  avoid  ulnar  deformity. 

This  shortening  of  the  ulnar  shaft  is  best  done  near  to,  but 
away  from,  the  wrist-joint,  and  may  be  most  easily  done  sub- 
periosteally  with  the  Gigli  saw  through  a  short  skin  incision.  It 
may  or  may  not  be  wise  to  suture  the  divided  ulna  with  absorb- 
able suture,  to  maintain  accurate  apposition.  The  wounds  are 
not  drained.  Obviously,  this  complete  operation  upon  radius 
and  ulna  is  appHcable  to  selected  cases  of  old  deformed  frac- 
ture. 

The  care  of  the  wrist  after  operation  is  like  the  care  fol- 
lowing an  ordinary  recent  uncomplicated  fracture. 


CHAPTER  XI 

FRACTURES  OF  THE  CARPUS,  METACARPUS,  AND 

PHALANGES 

FRACTURE  OF  THE  CARPUS 

SiMPivE  fracture  of  the  carpal  bones  is  unusual.  It  is  associated 
with  other  injuries.  It  is  not  uncommonly  seen  in  crushes  re- 
sulting in  open  fracture.  The  scaphoid  is  found  fractured  in 
certain  Colles'  fractures  and  in  falls  upon  the  outstretched  hand. 

Fractures  of  the  scaphoid  may  be  divided   into  the   fresh  or 


—  — •  Scaphoid. 


Fig.  469. — Normal  wrist  (X-ray  tracing). 


acute  and  the  old  or  chronic  cases,  (a)  The  acute  fracture  causes 
pain  and  tenderness  in  the  radial  side  of  the  wrist  in  the  region 
of  the  scaphoid,  together  with  some  swelling,  muscular  spasm,  and 
loss  of  function  of  the  wrist.  Imi  lobilization  of  the  wrist  for  a 
few  (two  or  three)  weeks,  passive  ai  d  active  movements,  and  mas- 
sage may  restore:  the  part  almost  i    not  completely  to  its  normal 

35  S 


Radius 


Scaphoid^- 
Trapezoid   — -^SB!^' 
Trapezium 


Metacarpal  bone 
of  thumb 


Articular  head  of  ulna 
I— Styloid  process  of  ulna 
Semilunar 

Cuneiform 


1 — Unciform 
Os  magnum 

Base  of  fifth  metacarpal  bone 


Styloid  process  of  third 
metacarpal  bone 


Heads  of  metacarpal  bones 


Fig.  470. — The  lower  ends  of  the  bones  of  the  forearm  and  the  carpal  and  metacarpal  bones  in 
their  natural  positions,  seen  from  the  dorsal  surface.  The  preparation  was  made  from  a  frozen  hand, 
whereby  the  relative  position  of  the  bones  could  be  perfectly  determined  (Sobotta  and  McMurrich). 


Styloid  process  of  ulna 

Semilunar- 

Pisiform 

Cuneiform 
Unciform 


Styloid  process  of  radius 
Tubercle  of  scaphoid 
Trapezoid 

-  Trapezium 


Fig.  471. 


Os  magnum  -f '"^»^Lfr,i^S^     ,4       Metacarpal  bone 

V-^       of  thumb 


-The  same  preparation  as  in  the  preceding  figure  seen  from  the  volar  surface  (Sobotta  and 
McMurrich). 


356 


Fig.  47- 


-X-ray  of  norniLil  wrist  (Codman 
and  Chase). 


Fig.  473.— Note  line  of  fracture  through 
scaphoid.  A  five-months'  "  sprained  wrist" 
(Codman  and  Chase). 


Fig.  474. — Note  line  of  fracture  of  right 
scaphoid  (Codman  and  Chase). 


Fig.  475. — Same  as  Fig.  474,  after  re- 
moval of  one  fragment  of  scaphoid.  Good 
ultimate  recovery  (Codman  and  Chase). 


Fi'g.  476. — Fracture    of    scaphoid    before 
operation  (Codman  and  Chase). 


357 


Fig.  477- — -Same  as  Fig.  470,  after  re- 
moval of  pro.ximal  fragment  of  scaphoid. 
Good  ultimate  result  (Codman  and  Chase). 


' 

1 

i^nj 

^^HH^ 

_j 

^H 

^^/k'' 

'■^tft 

IP 

m 

^^m 

^ 

•/ 

n^ 

7? 

..av* 

Fig.  478. — A  transverse  fracture  of  the  scaphoid.     Arrow  points  to  the  fracture  line. 


Fig.  479. — X-ray  taken  after  the  removal  of  the  inner  fragment  of  the  fractured  scaphoid.  Note 
the  fragment  left  in  situ  and  the  light  space  formerly  occupied  by  removed  fragment.  Arrow  points  to 
the  fragment  remaining. 

358 


FRACTURK  OF  THE  CARPUS  359 

condition.  There  more  often  persists  a  disability  calling  for  the 
second  group  of  scaphoid  fractures,  (b)  The  chronic  cases.  These 
cases  consult  the  surgeon  because  of  continued  pain  in  hyper- 
extension  and  a  weakened  wrist  following  trauma  to  the  part. 

Examination  finds  that  the  movements  of  the  wrist  are  limited, 
especially  in  hyperex tension.  There  is  muscular  spasm  in  the 
extremes  of  motion.  There  is  no  crepitus  or  ecchymosis;  over 
the  radial  side  of  the  wrist  there  is  swelling.  Tenderness  is  present 
over  the  scaphoid.  An  X-ray  will  discover  a  fracture  trans- 
versely across  the  scaphoid. 

In  the  differential  diagnosis  in  the  acute  cases  one  must  consider 
a  fracture  of  the  lower  end  of  the  radius  a  fracture  of  the  meta- 
carpal bone  of  the  thumb.  In  the  chronic  cases  must  be  distin- 
guished some  form  of  chronic  arthritis,  a  tuberculosis  of  the 
wrist,  and  an  inflammatory  bursitis  of  the  extensor  tendons  on 
the  radial  side  of  the  wrist. 

Treatment  of  the  Early  Fresh  Fracture. — Complete  immobilization 
of  the  wrist  joint  will,  if  made  from  the  beginning,  probably 
result  in  union.  But,  as  Codman  has  pointed  out,  immobiUzation 
must  be  continuous  and  for  at  least  a  period  of  three  weeks. 
Massage  should  then  be  employed  for  three  or  four  weeks.  If 
at  the  end  of  this. time  the  function  has  not  improved  and  the 
X-ray  shows  no  union,  operative  treatment  should  be  employed. 

Treatment  of  the  Chronic  Cases. — If,  after  proper  rest  and 
massage,  improvement  does  not  take  place,  the  Codman  operation 
should  be  done  for  removal  of  one  of  the  fragments  of  the 
scaphoid.  Removal  of  the  v/hole  bone  is  likely  to  be  followed 
by  a  weakness  of  the  wrist.  An  incision  is  made  on  the  dorsum 
of  the  wrist  over  the  scaphoid  to  the  inner  side  of  and  parallel 
to  the  border  of  the  extensor  carpi  radialis  longior  tendon.  The 
annular  ligament  is  divided,  the  scaphoid  exposed,  the  seat  of  the 
fracture  brought  into  view  by  abduction  and  flexion  of  the  wrist, 
the  fragment  to  be  removed  freed  from  its  ligamentous  attach- 
ments by  tenotome  or  scissors,  and  removed.  The  smallest  frag- 
ment is  the  best  one  to  remove,  according  to  recent  experience. 
The  wound  is  best  closed  by  interrupted  layer  sutures  and 
drained  by  a  bit  of  rubber  tissue  for  twenty-four  hours.  The 
wrist  should  be  immobilized  for  two  weeks  (see  Figs.  453  and 


360  FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

455))    but  during   this  time    gentle   passive   and   active   motion 
should  be  used  to  secure  normal  movements. 

The  wisdom   of  excision  of   one   or  both  scaphoid  fragments 
immediately  after  the  fracture  as  a  routine  procedure  is  yet  to 


I'lg.  4S0. — Fracture  of  the  scaphoid.     The  two  frag-nients  are  seen  near  the  styloid  of  the 
radius  (X-ray  tracing-)  (Balch). 


'WM. 


>',^j 


rlt<i 


Scaphoid  fragment. 

Scaphoid  fragment. A 


Fig.  481. — Case  :  Fracture  of  the  scaphoid  (X-ray  tracing). 


be  demonstrated.  In  view  of  the  usually  crippled  wrist  following 
this  fracture  under  non-operative  treatment,  operation  is  to  be 
seriously  considered  under  the  conditions  just  mentioned. 


FRACTURE    OF   THE    METACARPAL    BONES  361 

If  for  any  reason  operation  is  decided  against,  the  wrist  will 
be  strengthened  somewhat  by  the  use  of  massage  and  the  wear- 
ing of  a  gauntlet. 

Codman's  method  of  taking  an  X-ray  of  the  scaphoid : 

"A  practical  way  to  obtain  a  good  picture  of  the  scaphoid  is  to 
place  the  two  wrists  of  the  patient  in  adduction,  and  to  place  the  tube 
in  a  position  over  the  midline  between  the  two  hands,  as  far  forward 
as  the  level  of  the  knuckles. 

"Another  point  which  it  is  well  to  bear  in  mind  in  making  the 
diagnosis  of  fracture  of  the  scaphoid  is  the  existence  of  two  more 
or  less  prominent  bony  ridges  on  the  neck  of  the  scaphoid  bone 
which  bound  the  edges  of  the  articular  surfaces.  These  ridges 
in  some  cases  are  very  prominent,  and  as  the  neck  of  bone  between 
these  two  ridges  is  the  thinnest  portion  of  the  bone,  it  is  apt  to 
give  the  appearance  of  a  fracture,  unless  the  X-ray  is  good  enough 
to  show  the  detail  definitely.  If  the  X-ray  picture  is  taken 
correctly,  and  a  good  view  of  the  bone  in  its  long  axis  obtained,  a 
positive  diagnosis  can  readily  be  made,  for  not  only  can  the  line 
of  fracture  be  seen,  but  often  the  exact  region  of  the  interruption 
to  the  trabecular  structure  of  the  bone." 

FRACTURE  OF  THE  METACARPAL  BONES 
The  third  and  fourth  metacarpal  bones  are  the  ones  most  com- 
monly broken.  The  fracture  is  due  to  a  blow  upon  the  knuckles. 
Symptoms. — The  deformity  is  characteristic.  The  very  con- 
siderable swelling  often  obscures  the  outline  of  the  bones,  but 
palpation  detects  the  lower  end  of  the  upper  fragment  in  the 
dorsum  of  the  hand,  while  the  upper  end  of  the  lower  fragment 
is  sometimes  felt  in  the  palm  of  the  hand.  This  deformity  is 
characterized  by  a  loss  from  the  line  of  the  knuckles  of  that 
knuckle  corresponding  to  the  fractured  metacarpal  (see  Figs.  485, 
486) .  Pain  and  crepitus  are  present.  The  hand  can  not  be  closed 
tightly  on  account  of  the  swelling  and  pain. 

To  obtain  crepitus  easily  and  to  assist  in  reducing  the  fracture, 
it  is  best  to  grasp  the  finger  corresponding  to  the  fractured  meta- 
carpal with  the  whole  right  hand,  steadying  the  injured  meta- 
carpus with  the  left  hand,  and  then  to  make  steady  and  continuous 
traction    (see   Fig.  487).     The   distal   fragment   is   so   short   and 


362      FRACTURES    OF    CARPUS,    METACARPUS,    AND    PHAIvANGES 

movable  that  unless  this  method  is  used  to  steady  the  fragment 
it  will  be  difficult  to  determine  crepitus  and  to  reduce  the  frac- 
ture. This  fracture  heals  readily.  Occasionally,  however,  a  sup- 
purative process  may  complicate  recovery  even  when  the  fracture 
is  not  an  open  one. 

Bennett's  fracture,  commonly  designated  "stave"  of  the  thumb 
and  "punch  fracture,"  should  be  mentioned  here.  The  fracture 
is  usually  caused  by  a  blow  on  the  end  of  the  thumb.     The  right 


Fig.  482. — Fracture  of  the 
base  of  the  metacarpal  bone  of 
the  thumb.  Rather  oblique, 
with  considerable  displacement 
of  thumb  toward  the  wrist. 


Fig.  483. — Fracture  of  the 
base  of  the  metacarpal  bone  of 
the  thumb.  Note  the  bowing 
of  the  fragments  backward. 


Fig.  484. — "Stave"  frac- 
fure  of  the  thumb.  Note  joint 
involved.  Note  displacement 
of  shaft  of  thumb  metacarpal. 


thumb  is  oftenest  involved.  The  bone  is  driven  against  the  trape- 
zium. It  is  a  fracture  of  the  proximal  end  of  the  metacarpal  of  the 
thumb,  obhque,  and  into  the  joint  with  the  trapezium.  The  meta- 
carpal bone  is  displaced  backward.  There  is  great  disability  in 
opposing  the  thumb  and  index-finger.  Grasping  small  objects  is 
impossible.     Pressure  upon  the  ball  of  the  thumb  is  painful. 

The  injuries  likely  to  be  mistaken  for  this  fracture  are  sub- 
luxation of  this  same  joint,  a  sprain  of  this  joint,  and  a  contusion 
of  this  part.     For  treatment  of  Bennett's  fracture  see  p.  372. 

Treatment.— After  reducing  the  fracture  of  the  metacarpal  bone 
by  traction  and  pressure,  as  suggested,  it  must  be  held  in  place  by 
special  padding,  for  the  deformity  tends  to  recur.     The  hand  and 


FRACTURE    OP   the;    metacarpal    BONES 


363 


forearm  are  supported  upon  a  properly  padded  palmar  splint.  A 
pad  is  placed  in  the  palm  over  the  prominent  lower  end  of  the 
metacarpal.  Another  pad  is  placed  upon  the  dorsum  of  the  hand 
over  the  upper  fragment.  These  pads  are  secured  by  narrow 
strips    of    adhesive    plaster.     The   whole  is  then    bandaged.     If 


Fig.  48s  .^A,  Fracture  of  neck  of  fourth  metacarpal  bone.  Swelling  of  finger  and  knuckle. 
Knuckle  has  dropped  downward  toward  the  palm.  B,  Normal  hand.  Line  of  knuckles 
shown.     Contrast  with  A. 


Fig.  486. — Fracture  of  the  fourth  metacarpal  bone.  View  of  two  hands  from  behind  :  A, 
Normal  line  of  knuckles.  B,  Knuckle  of  the  ring-finger  has  dropped  downward.  Deformity 
well  shown. 


after  carefully  padding  the  two  fragments  and  immobilizing  them 
the  deformity  is  reproduced,  the  fragments  slipping  by  each 
other,  it  may  be  necessary  to  make  permanent  traction  upon 
the  finger  (see  Fig,  488).     This  is  best  done  by  applying  narrow 


Fig.  4S7. — Method  of  graspi: 


g  hand  and  finger  in  examining  for  fracture  of  metacarpal  bone, 
and  in  reducing  such  a  fracture. 


Fig.  4SS. — Fracture  of  the  neck  of  the  second  metacarpal.  Method  of  securing  extension. 
Note  adhesive  plaster,  rubber  tubing,  peg,  padding  to  finger,  pad  over  proximal  fragment. 
Counterextension  by  adhesive  plaster  about  wrist.     Ready  for  the  application  of  a  bandage. 


Fig.  489. — Fracture  of  the  metacarpal  of  the  index-finger.     Use  of  roller  bandage, 
of  roller  bandage.     Method  of  traction  and  countertraction. 

364 


Position 


FRACTURE  OF  THE  METACARPAL  BONES 


36- 


adhesive-plaster  straps  to  the  sides  of  the  finger  held  in  place 
by  circular  and  oblique  straps.  The  hand  rests  upon  the  palmar 
splint.      An   adhesive-plaster   circular   band    passed    about    the 


Fig.  4QO. — Fracture  of  the  metacarpal  of  the  index-finger.     Completion  of  traction.     Pressure 
and  counterpressure  by  thumb  on  the  dorsum  and  on  bandage  in  the  palm  of  the  hand. 


Fig.  491 — Fracture  of  the  metacarpal  of  the  index-finger.     Completion  of  the  application  of 
the  dressing.     Adhesive-plaster  straps  holding  hand  and  roller  bandage  in  position. 


wrist  and  splint  offers  continuous  countertraction.     If  the  band 
is  carried  between  the   thumb   and   forefinger,   greater  security 


Fig.  492. — Common  fracture  of  the  neck  of  the 
fourth  metacarpal  bone  with  some  impaction. 


Fig.  493. — Oblique  fracture,  "stave"  of  the 
base  of  the  second  metacarpal  bone.  Joint 
opened. 


Fig.  494. — Fracture  of  the  shaft  of  the  fifth 
metacarpal  bone. 


Fig.  495. — Comminuted  fracture  of  the  first 
phalanx  of  the  index-finger  without  serious  dis- 
placement. 


366 


Fig.  496. — Transverse  fracture  of  the  first 
phalanx  of  the  thumb,  with  some  displacement 
and  sliding  by  of  distal  fragment. 


Fig.  497. — Fracture  of  the  terminal  phalanx  of 
the  index-finger. 


Fig.  498. — Unusual  frac- 
ture of  the  base  of  the  termi- 
nal phalanx  of  the  thumb. 


Fig.  499. — Oblique  fracture 
(lateral  view)  of  the  shaft  of 
the  first  phalanx  of  the 
thumb,  some  shortening. 


Fig.  500. — Oblique  fracture  of  the 
first  phalanx  of  the  thumb  without 
much  displacement. 


.^67 


UJtr^-'^'^ 


■2<ieyuMMMM. 


jUt%A  n.'fi^^i'i'i'' 


Fig.  501. — Showing  diagrammatically  the  line  of  fracture  at  the  base    of  the  first  metacarpal  bone. 
Bennett  fracture.     Note  that  the  joint  is  involved. 


Fig.  502. —  Oblique  fracture  of  the  fifth  metacarpal  bone  near  its  base. 


Fig.  503. — Fracture  of  the  finger. 
Wooden  splint  applied  to  the  palmar  sur- 
face.    Note  straps  and  length  of  splint. 


Fig.  504. — Finger    splint    of    copper  wire 
applied. 


368 


Fig.  505. — Fracture  of  the  first  metacarpal  bone,  extension  straps  applied  (Robinson). 


FiK-  So<). — Appli(  .ilion  of  sjilint  wood  strips  to  lengthen  extension  trough  in  plaster  spica  to  beyond  the 
tip  of  the  thumb  (Robinson). 

24  369 


Fig.  507. — First  plaster-of-Paris  spica  applied.     Operator's  left  thumb  should  rest  at  O  to  depress 
plaster  at  the  seat  of  fracture  (Robinson). 


Fig.  508. — Dressing  completed.     Splint  wood  withdrawn.     Extension  strips  drawn  tight  over  end  of 
plaster  trough  and  buckled  (Robinson). 


Fig.  509. — A,  Finger  splint  applied  to  middle  finger,  three  straps.     Note  position  of  splint  ir 
palm  of  iiand.     B,  Finger  splint  of  aluminium  or  tin,  anterior  surface. 


Fig.  SIO-— Palmar  wooden  thumb  splint.    Note  shape,  pads,  straps,  position. 


372   FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

is  obtained,  and  there  is  much  less  likelihood  of  slipping  of  the 
plaster.  The  extension  upon  the  finger  is  obtained  by  fastening 
the  extension  strips  to  small  pieces  of  rubber  tubing,  and  carry- 
ing the  tubing  around  a  wooden  peg  or  screw  passed  through  a 
hole  in  the  splint. 

A  simple  contrivance  for  a  fracture  with  little  displacement 
is  the  use  of  a  roller  bandage  (see  Figs.  489-491  inclusive).  A 
roller  bandage  of  cotton  cloth  that  is  firmly  and  not  easily  com- 
pressed and  of  a  size  comfortable  for  the  hand  to  grasp  is  selected. 
This  is  placed  in  the  palm  of  the  extended  hand;  the  fingers 
and  metacarpal  heads  are  drawn  down  firmly  over  it.  This 
position  is  maintained  by  a  broad  strip  of  adhesive  plaster  around 
the  whole  hand.  Pads,  as  with  the  palmar  splint,  may  be  used 
to  reinforce  the  roller  bandage.  Unless  great  care  is  exercised, 
this  method  will  result  in  posterior  bowing  of  the  metacarpal 
bone.  If  there  is  an  anterior  displacement  of  either  or  both 
fragments,  this  roller-bandage  apparatus  is  very  efficient  in 
maintaining  reduction  of  the  deformity. 

This  apparatus  should  be  carefully  inspected  each  day  during 
the  first  week,  to  be  sure  that  the  position  obtained  is  held  firmly. 
After  three  weeks  the  splint  may  be  omitted.  Massage  during 
the  third  week  will  be  of  benefit.  Great  care  must  be  exercised 
in  the  use  of  the  hand  following  the  removal  of  the  splint  until 
the  fourth  week  is  passed,  for  deformity  may  result. 

For  the  treatment  of  a  Bennett  fracture  of  the  thumb  a  small 
palmar  splint  with  traction  upon  the  thumb  and  local  pressure  over 
the  backwardly  dislocated  fragment  is  good  treatment.  Robin- 
son's device  for  accomplishing  traction  and  local  pressure  are 
shown.  In  cases  difficult  to  hold  this  method  will  be  found 
efficient.  After  about  two  weeks  gentle  active  motion  is  allowed. 
Massage  should  be  begun  the  day  following  the  injury. 


FRACTURE    OF   THE    PHALANGES  373 

FRACTURE  OF  THE  PHALANGES 
The    bones    lie    subcutaneously ;    fractures    of    the    phalanges 
are,  accordingly,  comparatively  easy  to  detect.     Fractures  near 


Fig.   511. — Lateral  splint  of  wood  for  fracture  of  the  thumb.     Note  pad  at  the  side  of  first 
phalanx,  to  correct  lateral  deformity. 


the  articular  surfaces  are  hard  to  detect  because  joint  crepitus 
is  deceptive.  The  so-called  base-ball  finger  may,  in  many  in- 
stances, be  associated  with  a  fracture  of  the  head  of  the  meta- 
carpal bone,  and,  involving  the  joint,  occasion  a  slow  conva- 
lescence. 

Symptoms. — Crepitus,  pain,  and  abnormal  mobility  are  pres- 
ent, and  occasionally  deformity  is  seen. 

Treatment. — It  is  important  that  the  alinement  of  the  phalanx 
be  maintained.  Rotation  of  the  lower  fragment  upon  its  long 
axis  is  especially  to  be  guarded  against.  Temporarily,  if  there 
is  much  swelling,  the  broken  finger  may  rest  upon  a  palmar 
splint,  the  two  adjoining  fingers  serving  as  lateral  splints  to 
steady  it.  The  contiguous  skin  surfaces  must  be  protected 
by  strips  of  cotton  cloth  and  a  drying  powder. 

A  single  splint  of  thin  wood,  extending  from  the  middle  of 
the  palm  of  the  hand  to  the  finger-tip,  and  held  in  position  by 
adhesive-plaster    straps,    is    most    useful    (see    Fig.    503)-     The 


374     I''RACTURES    OF    CARPUS,    METACARPUS,    AND    PHALANGES 

splint-wood  used  should  be  cut  thin  and  not  left  thick  and  bung- 
ling— half  the  thickness  of  the  wood  of  an  ordinary  cigar  box 
is  about  right.  The  splint  should  be  a  little  narrower  than  the 
finger  itself.     A  narrow  cotton  bandage  applied  over  the  finger 


C 


7  x.I'/z 


Fig.  512. — Thumb  splint :  a,  Pattern— measurements  are  in  inches  ;  <!',  position  of  splint.     Note 
extension  of  thumb  (after  Goldthwaite). 

or  a  simple  cot  to  cover  the  finger  will  be  comfortable  and  will 
assist  in  immobilization.  Ordinary  letter-paper,  by  continued 
folding,  may  be  made  into  a  narrow  and  suitable  splint.  This 
is  simple  and  efficient.  It  should  be  held  in  place  by  a  bandage 
or,  preferably,  by  a  cot.  Ordinary  copper  wire  may  be  used, 
as  shown  in  the  illustration,  without  any  padding  (see  Fig.  504). 
This  serves  as  a  proper  protection  after  the  first  week  or  two, 
and  is  not  so  clumsy  as  other  splints.  The  aluminium  or  tin 
finger  splint  is  easily  made  and  satisfactory  (see  Fig.  509).  Any 
displacement  in  this  fracture  may  be  easily  adjusted  by  narrow 
adhesive  straps  and  small  pads. 

Fractures  of  the  first  and  second  phalanges  of  the  thumb 
may  be  satisfactorily  treated  after  reduction  upon  a  dorsal  or 
lateral  splint  of  wood,  if  proper  padding  is  employed  (see  Figs. 
510,  511).  Frequently,  however,  the  tin  splint  fitted  to  the 
cleft  between  the  thumb  and  forefinger,  as  shown  in  the  illus- 
tration (Fig.  512),  will  immobilize  these  fractures  more  securely 
and  comfortably. 


OPEN  FRACTURES  OF  THE  PHALANGES  375 

Open  Fractures  of  the  Phalanges.  These  may  be  followed 
by  profuse  suppuration  from  necrosis  of  the  fractured  bones. 
This  fracture  is  to  be  treated  with  extreme  care,  especially  as 
regards  antisepsis.  Immobilization  should  continue  at  least 
four  weeks.  If  at  the  end  of  this  time  union  has  not  occurred, 
the  patient  may  be  given  the  option  of  continuing  the  treatment 
or  of  having  the  finger  amputated.  If  union  does  not  occur 
after  four  weeks  of  careful  treatment,  it  is  highly  improbable 
that  it  will  ever  occur.  Resection  of  the  bones  may  be  attempted 
before  amputation. 


CHAPTER  XII 
FRACTURES  OF  THE  FEMUR 

FRACTURE  OF  THE  HIP  OR  NECK  OF  THE  FEMUR 
Anatomy. — The  crest  of  the  ilium  can  be  felt  throughout  its 
entire  extent,  from  the  anterior  superior  spine  to  the  posterior 
superior  spine.  The  posterior  superior  spine  corresponds  to  the 
level  of  the  center  of  the  sacro-iliac  synchondrosis.  The  great 
trochanter  of  the  femur  is  easily  distinguished  even  in  fat  in- 


Fig.  513- — Nelatoii's  line  (A  D)  from  anterior  superior  spine  of  the  ilium  to  the  tuberosity 
of  the  ischium.  A  C  X,  Bryant's  triangle.  Distance  (X  C)  from  top  of  trochanter  to  perpen- 
dicular (A  B)  dropped  from  anterior  spine  to  horizontal  table  top  is  Bryant's  measurement. 
After  fracture  this  measurement  may  be  less  than  normal. 


dividuals.  Nelaton's  line  is  determined  by  stretching  a  tape 
from  the  anterior  superior  spine  of  the  ilium  to  the  tuberosity 
of  the  ischium.  The  top  of  the  great  trochanter  lies  at  or  a  little 
below  Nelaton's  line,  and  about  opposite  to  the  symphysis  pubis. 
The  internal  condyle  of  the  femur  looks  in  the  same  general 
direction  as  the  head  and  neck  of  the  femur  (see  Figs.  514,  515). 

376 


fracture;  of  the;  neck  of  the  femur 


377 


The  anterior  superior  spine  of  the  ihum  is  of  importance  because 
from  it  measurement  is  made  in  taking  the  length  of  the  legs 
after  fracture  of  the  femur.  Normally,  the  fingers  can  be  hooked 
behind  the  great  trochanter  toward  the  posterior  surface  of  the 
neck  of  the  bone.  By  this  manipulation  the  posterior  portion 
of  the  capsule  of  the  joint  can  be  felt. 


Fig.  514. —  Femur,  from  front.  Note 
normal  relation  of  direction  of  head  and 
neck  to  that  of  internal  condyle. 


Fig.  Si.S- — Femur,  from  outer  side. 
Note  normal  anterior  bowing  and  relation 
of  direction  of  head  and  neck  to  that  of  in- 
ternal condyle. 


Fracture  of  the  Neck  of  the  Femur  in  Adults. — This  accident 
occurs  most  frequently  in  elderly  people.  It  ordinarily  is  associ- 
ated with  a  very  slight  injury,  such  as  a  trip  and  fall  upon  the 
floor  from  the  standing  position.  Undoubtedly,  in  many  in- 
stances the  fracture  precedes  the  fall.     It  is  often  difficult   to 


Fig.  Si6. — Vertical  section  of  hip-joint,  seen  from  behind.  The  angle  which  the  head  under 
normal  conditions  forms  with  the  shaft  (127  degrees)  is  marked  out.  /,  Rim  of  acetabulum  in  vertical 
section.  C,  Cavity  of  joint  (exaggerated),  showing  the  extent  of  the  joint  capsule.  L,  Ligamentum 
teres  (Eisendrath). 


Fig.  S17. — Adult  femur.     Upper  portion  of  shaft  and  head  and  neck.     The  lines  show  the 
usual  seats  of  fracture  of  the  neck  of  the  bone. 


Fracture;  of  the  neck  of  the  femur — symptoms  379 

determine  the  exact  seat  of  the  lesion.  Whether  the  fracture 
is  within  or  without  the  capsule  of  the  joint  is  of  comparatively- 
little  moment.  On  the  other  hand,  whether  the  fracture  is 
impacted  or  unimpacted  is  of  the  greatest  importance.  Frac- 
tures of  the  base  of  the  neck  of  the  bone — that  is,  fractures  near 
the  trochanter — are  usually  impacted.  Fractures  of  the  neck 
toward  the  head  of  the  bone  are  usually  unimpacted  (see  Fig. 
517).  Impacted  fractures  unite  readily.  Unimpacted  fractures 
often  remain  ununited. 

Symptoms. — The  patient  is  unable  to  rise  from  the  ground. 
A  contusion  may  be  seen  over  the  hip  as  a  result  of  the  fall.  There 
is  pain  in  the  hip  while  the  patient  is  lying  still.  This  pain  is 
increased  upon  motion  at  the  hip.  There  is  inability  to  move 
the  injured  leg  easily  and  painlessly.  There  is  limitation  of 
motion  of  the  injured  leg.  While  lying  upon  the  back  it  is  im- 
possible for  the  patient  to  raise  the  heel  from  the  bed.  The 
foot  is  everted,  the  leg  having  rolled  outward.  The  whole  ex- 
tremity lies  helpless  (see  Fig.  520).  There  is  a  slight  appreciable 
fullness  below  the  fold  of  the  groin.  This  fullness  in  the  outer 
upper  part  of  Scarpa's  triangle  corresponds  to  a  non-depressible 
area  associated  with  fracture  of  the  neck  of  the  femur.  Slight 
shortening  of-  the  leg  exists.  After  three  or  four  days  this  shorten- 
ing may  increase  to  two  inches.  The  trochanter  is  above  Nel- 
aton's  line.  The  fascia  above  the  trochanter  is  relaxed.  This 
is  especially  noted  in  the  standing  position,  with  the  patient 
resting  the  weight  upon  the  well  leg.  If  the  fracture  is  an  im- 
pacted one,  crepitus  will  be  absent  upon  gentle  manipulation, 
unless  the  impaction  has  been  broken  up  by  some  unwise  means. 
If  the  fracture  is  unimpacted,  crepitus  can  be  detected  by  the 
hand  while  traction  or  gentle  rotation  of  the  leg  is  made.  The 
foot  is  everted  whether  impaction  is  present  or  not.  If  the 
impaction  is  of  the  anterior  portion  of  the  neck,  inversion  will 
be  present  ;  if  the  impaction  is  of  the  posterior  portion  of  the 
neck,  eversion  will  be  present  (see  Figs.  521,  522).  Impacted 
eversion  can  not  be  inverted  nor  can  impacted  inversion  be 
everted  without  breaking  up  the  impaction.  In  these  cases  of 
marked  eversion  and  inversion  a  dislocation  of  the  hip  must  be 
excluded  if  possible. 


38o 


FRACTURES    OF    THE    FEMUR 


Fig.  Si8.— Note  the  forward  arch  of  the  shaft  of  the  femur.    This  arching  forward  should  be 
taken  into  account  in  the  padding  of  splints  in  the  case  of  femoral  shaft  fractures. 


Fig.  519. — Note  strong  iliotibial  thigh  fascia  with  heavy  muscular  insertions  at  the  upper 
part.  It  is  the  retraction  of  this  fascia  which  often  assists  to  make  difficult  reduction  of 
femoral  shaft  fractures. 


Examination. — A  prolonged  search  for  crepitus  and  abnormal 
mobility  must  never  be  attempted.  In  order  to  avoid  unneces- 
sary movement  of    the  hip  and  because  inspection  and  gentle 


FRACTURE  OF  THK  HIP — EXAMINATION 


3«I 


palpation  alone  will  so  often  decide  the  diagnosis,  it  is  wise  to 
follow  a  routine  examination. 

The  history  of  the  accident  should  be  obtained.  The  pres- 
ence and  location  of  pain  are  determined.  How  much  is  the 
functional  usefulness  of  the  leg  involved?  What  does  inspection 
reveal  as  to  the  local  condition  and  the  position  of  the  limb  ? 
What  does  palpation  reveal?  How  do  the  measurements  of  the 
leg  and  the  trochanter  compare  with  similar  measurements  of 
the  uninjured  leg?  Last, — and  to  be  avoided  if  a  diagnosis  has 
been  reached, — what  does  gentle  manipulation  show  as  to  the 
presence  of  crepitus  in  the  hip? 

In  order  to  make  a  systematic  examination  all  clothing,  of 
course,  should  be  removed  from  the  patient.  He  then  should 
be  placed  upon  a  firm  and  even  surface.     A  hard  mattress,   a 


Fig.   520. — Case  :    Impacted  fracture  of  the  left  hip.     Note  helpless  attitude   of    limb  ;  foot 

everted. 


table,  or  a  comforter  spread  upon  the  floor  will  provide  the 
necessary  conditions.  An  anesthetic  is  hardly  ever  necessary 
for  diagnostic  purposes.  If  an  anesthetic  is  employed,  the  hip 
should  be  handled  in  the  gentlest  manner  possible.  With  an 
anesthetic  all  muscular  spasm  is  abolished;  therefore,  move- 
ments of  the  hip  are  made  without  the  protection  of  volun- 
tary muscular  spasm.  All  sudden  quick  movements  should  be 
avoided.  There  is  great  danger  that  an  impacted  fracture  of 
the  hip  may  be  changed  by  rough  handling,  especially  in  the 
movement  of  rotation,  to  an  unimpacted  fracture.  Palpation 
of  the  neck  of  the  femur  with  the  thumb  in  front  of,  and  the 
fingers  behind,  the  great  trochanter  will  detect  any  irregularity 
or  thickening  and  tenderness  about  the  neck  of   the  bone  (see 


382 


FRACTURES    OF    THE    FEMUR 


Fig-  530)-  By  palpation  of  the  great  trochanter  one  may  dis- 
cover there  the  seat  of  fracture.  SwelHng,  tenderness,  and 
crepitus  may  be  found.  Only  gentle  strong  traction  in  the  line 
of  the  long  axis  of  the  thigh  should  be  made  to  elicit  crepitus 
and  abnormal  motion. 


Fig.  521  — Fracture  of  the  hip.  Inward 
rotation  of  the  leg  because  of  impaction  of 
the  anterior  portion  of  the  neck  of  the 
bone. 


Fig.  522. — Fracture  of  the  hip.  Outward  rotation 
of  the  leg  because  of  impaction  of  the  posterior  por- 
tion of  the  neck  of  the  bone. 


Measurement. — The  absence  of  any  preexisting  injury  or 
disease  of  the  hip  under  consideration  is  always  to  be  carefully 
noted.  Measurement  should  always  be  made  with  the  patient 
lying  on  the  back.  The  leg  should  be  brought  gently  along- 
side of  its  fellow,  and  steadied  by  an  assistant.  Measurement 
should  be  made  from  the  anterior  superior  spine  of  the  ilium  to 
the  internal  malleolus  upon  each  side  (see  Fig.  567).      If  there 


FRACTURE    OF    THE)    HIP — MEASUREMENT 


383 


is  shortening  upon  the  injured  side,  a  fracture  with  some  displace- 
ment is  Hkely  to  have  occurred.  A  normal  difference  in  the  length 
of  the  lower  limbs  is,  however,  not  unusual.  It  is,  therefore, 
necessary  to  determine  the  presence  of  asymmetry  if  it  exists, 
if  any  confidence  is  to  be  placed  in  the  measurements  of  the  legs. 
Measurements  should,  therefore,  be  made  of  the  tibia  upon  the 
two  sides,  and  these  compared.  If  no  asymmetry  appears 
to  be  present,  any  differences  in  measurement  may  be  taken 
to  be  absolute.     If  it  is  impossible  to  bring  the  legs  parallel,  they 


Fig.  523. — Old  fracture  of  femoral  neck  ; 
no  union.  Absorption  of  whole  neck  of 
bone.  There  is  some  atrophy  of  the  whole 
shaft  of  the  femur  (Warren  Museum,  speci- 
men 8075). 


Fij;.  524. — Fracture  of  femoral  neck.  Im- 
paction of  base  into  the  shaft  (Warren  Mu- 
seum, specimen  6303). 


must  be  placed  in  the  same  relative  positions  to  the  median  line 
of  the  body. 

Bryant's  method  of  measurement  is  simple  and  of  service.  The 
limbs  are  placed  symmetrically.  The  top  of  the  trochanter 
is  marked  upon  the  skin.  A  perpendicular  line  is  dropped  from 
the  anterior  superior  spine  to  the  table  upon  which  the  patient 
lies.  Measurement  is  made  from  the  top  of  the  trochanter  to 
this  perpendicular  line.  If  fracture  of  the  neck  of  the  femur 
has  occurred,  and  there  is  displacement  or  shortening  of  the 
limb,  the  distance  from  the  perpendicular  to  the  top  of  the  tro- 
chanter will  be  less  than  a  like  measurement  on  the  uninjured 
side.  The  position  of  the  top  of  the  great  trochanter  is  deter- 
mined with  reference  to  Nelaton's  line.     If  the  leg  is  rolled  out- 


384 


FRACTURES    OF    THE   FEMUR 


ward,  dislocation  of  the  hip  forward  would  be  suspected,  but  the 
absence  of  the  head  of  the  bone  anteriorly  and  the  absence  of 


Fig.  S25-— Fracture  of  the  neck  of  the  femur  close  to  the  head  at  outer  part  of  the  neck 
(Warren  Museum  specimen). 


Fig.  526 — Fracture  of  the  neck  of  the  femur  at  base  (Warren  Museum  specimen). 


other   positive    signs    should    eliminate    dislocation.     If    the    leg 
is  rolled  inward,  a  dislocation  of  the  hip  upon  the  dorsum  ilii 


FRACTURE  OF  THE  HIP — PROGNOSIS  385 

would  be  considered.  The  absence  of  other  positive  signs  of 
dislocation  and  the  presence  of  the  head  of  the  bone  in  the  acet- 
abulum should  convince  one  of  the  nonexistence  of  dislocation. 
In  an  elderly  person  who  presents  no  well-marked  sign  of  frac- 
ture, but  who  is  unable  to  use  the  limb  after  ever  so  slight  an 
injury,  a  fracture  of  the  hip  should  be  so  strongly  suspected  that, 
until  the  Rontgen  ray  proves  it  absent,  he  should  be  treated 
as  if  a  fracture  were  present. 

Prognosis  and  Result. — In  the  very  aged  and  feeble  the  shock 
of  a  fracture  of  the  neck  of  the  femur  is  severe.  The  danger 
to  life  in  these  cases  is  great.  An  elderly  patient  may  die  of 
shock  within  two  or  three  days,  or  within  a  week  of  hypostatic 


Fig.  527.— Fracture  of  femoral  neck,  unimpactcd  ;  fibious  union,  with  absorption  of  the  neck 
(Warren  Museum,  specimen  3651). 

pneumonia,  or  he  may  live  several  weeks  and  die  of  exhaustion 
because  of  pain  and  the  enforced  confinement.  If  the  fracture 
can  be  treated  with  proper  immobilization,  union  will  occur 
in  most  cases.  The  impacted  cases  will  unite;  the  unimpacted 
cases  may  unite.  Slight  shortening  with  a  little  deformity, 
some  limitation  in  the  movements  of  the  hips,  a  limp,  but  a 
fairly  useful  limb,  are  to  be  hoped  for.  Chronic  rheumatism 
will  often  prevent  a  fractured  hip  from  ever  becoming  useful. 
Nonunion  of  the  hip-fracture  does  not  preclude  a  useful  limb 
(see  Fig.  531).  Ununited  fractures  of  the  hip  are  greatly  bene- 
fited by  proper  ambulatory  apparatus.  They  may  be  made 
to  unite  by  mechanical  means  even  several  weeks  and  months 

25 


386 


FRACTURES    OF    THE   FEMUR 


after  the  injury.     This  is  particularly  true  of  fractures  occurring 
in  young  adults. 


Fig.  528. — Fracture  of  the  neck  of  the  femur  (Warren  Museum  specimen). 


Fig.  529. — Note  line  of  fracture  extending  into  shaft. 


Results  after  Fracture  of  the  Hip  (treated  by  the  method  of  im- 
mobilization, traction,  and  countertraction ;  the  customary  present 
method,  described  on  pages  389-409). — Of  especial  value  in  this 


FRACTURU    OF    THE    HIP — TRE;aTME;nT 


387 


connection  are  the  conditions  existing  in  sixteen  cases  of  fracture 
of  the  hip,  many  years  after  the  accident.  These  sixteen  cases  were 
treated  by  traction  and  immobihzation  for  periods  varying  from  a 
few  weeks  to  a  few  months.  The  patients  then  went  about  with 
crutches.  No  other  treatment  was  used.  Nearly  all  the  cases 
were  unimpacted  either  primarily  or  secondarily.  At  the  time 
of  the  accident  seven  cases  were  between  forty-two  and  forty- 
seven  years  old,  the  remainder — with  two  exceptions,  whose 
ages  are  not  stated — were  over  fifty;  three  were  over  sixty  years 
old.  These  cases  reported  for  examination  from  two  and  one- 
half  to  twenty-four  and  one-half  years  after  the  accident.  Thir- 
teen of  the  sixteen  cases  have  impairment  of  the  functional  use- 
fulness of  the  leg;  a  weakness  of  the  limb,  necessitating  a  crutch 
in  many  instances ;  all  movements  at  the  hip  somewhat  restricted ; 


Fig.  S3°- — Method  of  palpating  tiie  trochanter  of  the  right  femur. 


atrophy  of  the  muscles  of  the  thigh,  buttock,  and  calf  of  the 
leg;  a  decided  limp,  requiring  a  cane;  pain  in  the  hip  extending 
down  the  thigh  even  to  the  sole  of  the  foot;  pain  at  night  in  the 
hip;  pain  in  going  up-stairs  and  in  stooping  over.  In  only  two 
cases  out  of  the  sixteen  could  it  be  said  that  the  leg  was  func- 
tionally useful.  These  cases  were  examined  very  critically  and 
the  facts  recorded  with  accuracy.  The  conclusion  is  evident  that 
the  old-time  method  of  treatment  of  fracture  of  the  neck  of  the 
femur  is  not  productive  of  satisfactory  results. 

Treatment. — General  Considerations.— Fractures  of  the  hip  or 
of  the  neck  of  the  femur  demand  the  greatest  tact  in  their  manage- 
ment. The  aged  respond  readily  to  care.  The  patient  should 
be  made  to  feel  as  comfortable  as  possible  while  confined  to  his 
bed.     Particular  attention  should  be  paid  to  diet  and  to  all  little 


388 


FRACTURES    OF    THE    FEMUR 


comforts.  The  discomforts  attendant  upon  immobilization  are 
often  very  great.  Let  the  days  spent  in  bed  be  made  especially 
attractive.  Be  sure  that  agreeable  friends  visit  the  patient, 
seeing  to  it  that  they  do  not  stay  so  long  a  time  as  to  weary  him. 
Let  them  interest  him  in  the  news  of  the  day,  so  that  he  may 
feel  that  he  is  keeping  up  with  events.  Employ  a  skilled  nurse 
to  minister  to  his  wants;  a  bright  and  cheerful  woman  nurse 
is  ordinarily  better  than  a  man  nurse.  The  pulse  is  to  be  care- 
fully watched  as  well  as  the  respiration.  A  moderate  amount  of 
alcohol  once  or  twice  a  day  with  meals  is  to  be  used.  The  courage 
of  the  aged  needs  bracing.  Bed-sores  develop  with  surprising 
rapidity.     Skilled    watchfulness   and    immediate   treatment   will 


Fig.  S3I. — Case  :  Man   forty-five   years    old.      Fracture  of   the  neck  of  the  femur.      Union 
ligamentous,  with  displacement.     Useful  limb  (X-ray  tracing). 


often  check  the  progress  of  a  red  pressure  spot.  The  part  ex- 
posed to  pressure  should  be  kept  very  clean  with  soap  and  warm 
water;  it  should  be  bathed  with  alcohol,  thoroughly  dried,  and 
well  dusted  with  powder  (starch  and  oxid  of  zinc,  equal  parts); 
and  the  pressure  should  be  relieved  by  proper  pads  or  cushions. 
If  the  heel  is  the  part  involved,  a  rubber  cushion  or  a  ring  made  of 
sheet  wadding  wound  with  a  bandage  may  be  used.     A  certain 


FRACTURE    OF    THE    HIP — TREATMENT  389 

amount  of  moving  about  in  bed  should  be  granted  to  old  peo- 
ple. Asthenic  hypostatic  pneumonia  from  long-continued  rest- 
ing in  one  position  is  not  uncommon.  Therefore,  moving  about  a 
little  in  bed,  to  the  extent  of  sitting  upon  a  bed-rest  at  varying 
angles,  is  beneficial.  Deep  rhythmical  breathing  while  lying 
flat  on  the  back  is  a  splendid  stimulator  of  the  circulation.  In 
the  case  of  a  fracture  of  the  neck  of  the  thigh-bone  occurring 
in  an  elderly  individual  have  great  regard  for  the  general  con- 
dition of  the  patient  and  immobilize  the  fracture  by  that  method 
which  seems  to  best  meet  the  anatomical  conditions. 

The  exact  method  to  be  employed  in  any  given  case  of  fracture 
of  the  neck  of  the  femur  will  depend  upon  several  conditions, 
namely,  the  age  of  the  individual,  the  amount  of  resulting  de- 
formity, the  opportunity  of  the  attending  surgeon  to  command 
details  necessary  to  the  perfection  of  the  technique  of  certain 
methods.  In  an  old  individual,  feeble  and  weak,  it  would  be 
obviously  absurd  to  attempt  the  third  ideal  method  if  there  were 
little  or  no  deformity,  and  it  might  be  unwise  to  use  this  third 
method  even  though  there  were  great  deformity. 

There  are  to-day  the  following  methods  of  caring  for  a  fracture 
of  the  neck  of  the  femur.  First  :  the  old-time  traction 
and  countertraction  by  weight  and  pulley  and  elevation  of  the 
foot  of  the  bed,  together  with  lateral  traction  when  indicated. 
Second  :  the  Thomas  hip-splint  method  with  or  without 
traction.  Third  :  the  method  of  forcible  abduction  and 
immobilization  by  plaster  of  Paris  with  or  without  continuous 
traction.     Fourth  :  the  method  of  pegging. 

The  first  method  is  in  common  use;  it  is  unsatisfactory  in 
many  cases.     Good  results  have  been  obtained  by  it. 

The  second  method  is  satisfactory  in  the  hands  of  a  few. 

The  third  method,  introduced  by  Whitman  (see  Bibliography), 
is  certainly  deserving  of  extended  trial.  It  has  been  used  in  a 
number  of  cases  of  fracture  of  the  femoral  neck  in  children,  and 
the  wisdom  of  its  application  in  similar  suitable  lesions  in  the 
adult  has  now  been  determined. 

Treatment  of  the  Fractured  Hip. — First  method,  the  usual 
traction  method.  The  patient  should  be  placed  upon  a  com- 
fortable, firm,  hair  mattress.     Underneath  the  mattress,  crossing 


y\ 


Fig.  532.— Case  :  Fracture  of  the  neck  of  the  femur  (X-ray  tracing). 


Hudtf 


&uai 


SM^tM^n 


CAmWgLL.A/^. 


ffA^ 


Fig.  533  —  Case  of  Dr.  Royal  Whitman,  N.  Y.  A  girl  sixteen  years  old.  Injured  by  a  fall 
from  a  carriage.  Fracture  of  the  neck  of  the  femur.  This  X-ray  was  taken  six  months  fol- 
lowing the  accident.  Note  that  the  arrows  a  and  b  point  to  the  seat  of  fracture.  The 
arrow  c  almost  touches  at  its  tip  the  rim  of  the  acetabulum  and  the  rounded  head  of  the 
femur. 

39° 


FRACTURE    OF    THE)    HIP — TREATMENT  391 

the  bedstead  from  side  to  side,  should  be  placed  several  wooden 
slats  about  eight  inches  apart.  These  bedslats  prevent  sagging 
of  the  mattress  and  much  consequent  discomfort.  Great  caution 
must  be  exercised  that  no  sudden  or  forcible  movements  of  the 
hip  are  made  which  might  break  up  the  impaction  of  the  bone  or 
cause  unnecessary  pain.  The  leg  should  be  placed  in  as  natural 
a  position  in  extension  as  possible.  The  knee  should  be  placed 
upon  a  pillow.  Extension  strips  of  adhesive  plaster  should  be 
appHed  to  the  leg  and  thigh  as  high  as  the  perineum,  and  should  be 
held  to  the  skin  by  a  gauze  roller  bandage.  A  weight  of  about  five 
pounds  should  be  apphed  to  the  extension  while  the  leg  is  gently 
rotated  and  carefully  placed  approximately  in  the  normal  position. 
The  foot  of  the  bed  should  be  elevated  to  the  height  of  six  inches 
in  order  to  secure  counterextension.  Long  and  heavy  sand-bags 
should  be  placed  on  each  side  of  the  leg  and  thigh  to  assist  the 
Hght  extension  in  affording  support  and  to  give  a  sense  of  security. 
The  heel,  as  mentioned  before,  should  be  properly  protected  from 
undue  pressure.  The  foot  should  be  kept  at  a  right  angle  with 
the  leg.  To  afford  still  greater  immobilization,  a  long  T-splint 
extending  from  below  the  foot  to  the  axilla  of  the  injured  side 
may  be  applied  by  straps  about  the  leg  and  a  swathe  about  the 
body  (see  Fig.  581).  I  have  found  that  the  application  of  a  strap, 
made  of  duck,  about  the  hip  and  pelvis,  is  of  great  use.  The  strap 
is  4  or  5  inches  wide  and  has  stitched  to  it  two  pads  of  leather 
three  or  four  inches  apart.  These  pads  are  adjusted  so  as  to  rest 
behind  and  in   front  of  the  great   trochanter  of  the   injured  hip. 

The  posterior  pad  accomplishes  what  the  molding  of  the  plaster- 
of-Paris  spica  does  in  the  Whitman  treatment — it  supports  the 
femur,  preventing  a  falling  or  dropping  or  rolling  of  the  femur 
backward  and  outward. 

The  strap  exerts  gentle  lateral  direct  pressure  on  the  trochanters. 
This  strap,  together  with  the  light  extension  in  an  abducted  posi- 
tion, will  often  be  found  of  service.  The  skin  over  the  trochanter 
and  pelvis  receiving  the  pressure  must  be  cared  for  with  bathing 
alcohol  and  powder. 

The  Maxwell  plan  for  treating  femoral  neck  fracture  of  (a)  flex- 
ing the  thigh  at  right  angles  to  the  trunk,  of  {b)  an  outward  trac- 
tion upon  the  upper  end  of  the  femur  in  order  to  correct  the  dis- 


392 


FRACTURES    OF   THE    FEMUR 


placement  in  fracture  of  the  neck,  (c)  the  adjustment  of  a  continu- 
ous lateral  traction,  (d)  and  direct  longitudinal  traction  by  a  Buck's 
extension.  This  plan  of  Maxwell  for  fracture  of  the  neck  of  the 
femur  is  a  good  one. 

After-care  of  the  Simple  Traction  Method. — The  general  care 
of  the  patient  should  be  as  outlined  previously.  He  should  be 
kept  quiet  in  bed  for  about  two  weeks.  During  the  second 
week  he  may  be  bolstered  up  on  pillows  to  the  half-sitting  posi- 
tion.    Ordinarily,    the   extension   may   be   removed    during    the 


Fig.  534 — Thomas'    single   hip-splint    in 
position  (Ridlon). 


Fig.  S3S- — ^Thomas'  double  hip-splint  in 
position  (Ridlon). 


third  or  fourth  week.  The  patient  may  then  be  lifted  to  another 
bed  or  divan  and  be  rolled  into  an  adjoining  room.  In  this  change 
the  thigh  should  be  supported  by  sand-bags.  The  patient  may 
be  up  in  a  wheel-chair  after  the  first  six  weeks  or  two  months 
with  the  knee  straight  or  flexed.  He  may  use  crutches  and  a  high 
shoe  upon  the  well  foot,  not  bearing  any  weight  upon  the  injured 
hip,  after  about  two  months  or  ten  weeks.  He  should  not  bear 
weight  upon  the  hip  even  with  the  assistance  of  crutches  for 
about  four  or  six  months. 

At  the  end  of  a  year  he  may  be  walking  with  one  cane.    The  fore- 


FRACTURE    OF    THE)    HIP — TREATMENT  393 

going  is  the  course  of  a  case  treated  according  to  the  old-time  simple 
extension  or  partial  immobilization  method.  It  is  a  matter  of  com- 
mon observation  that  some  impacted  hips  recover  with  fairly  useful 
limbs  with  this  treatment.  Impacted  hips  are  known  to  have  recov- 
ered with  useful  limbs  without  any  medical  or  surgical  advice  or 
treatment,  the  impacted  fracture  having  been  thought  at  the  time 
of  injury  in  the  absence  of  marked  deformity  to  be  a  severe  con- 
tusion, which  would  be  all  right  in  time.  These  cases  have  occurred 
both  among  adults  and  children. 

Greater  immobilization  of  the  impacted  and  unim.pacted  hip 
is  demanded  in  most  cases  than  can  be  obtained  by  the  simple 
traction  and  countertraction  previously  described.  The  simple 
method  is  far  from  ideal :  malunion  and  non-union  with  resulting 
disability  too  often  follow  its  use,  the  period  of  disability  is  long, 
and  the  ultimate  results  are  often  most  unsatisfactory.  Very 
refractory  individuals  will  have  to  be  left  pretty  much  to  them- 
selves.   No  great  restraint  can  to  advantage  be  forced  upon  them. 

The  Second  Method. — The  Fixation  Method  of  Treatment. — In  order  to 
put  the  unimpacted  bones  of  the  hip-joint  under  the  very  best  conditions  for 
union  to  take  place,  not  only  must  the  fragments  be  approximated  by  traction, 
correction  of  eversion  or  inversion,  and  lateral  pressure  over  the  trochanter 
major,  but  these  fragments  must  be  firmly  fixed.  In  order  to  immobilize  these 
fragments  absolutely  the  body  or  pelvis  and  the  thigh  must  be  fixed.  The 
simple  method  already  described,  in  spite  of  the  fact  that  it  has  been  used  for 
many  years  in  these  cases,  does  not  absolutely  immobilize.  A  comfortable 
and  efficient  method  of  immobilization  is  by  the  use  of  the  Thomas  hip-splint. 
The  description  which  follows  of  the  Thomas  hip-splint  and  its  use  is  that 
given  by  Ridlon.  The  method  requires  a  certain  skill  in  adjustment  and 
necessitates  the  employment  of  definite  materials  not  always  easily  obtain- 
able.    It  is,  therefore,  not  a  method  of  universal  application. 

The  Thomas  hip-splint  secures  posterior  support  to  the  fracture,  gives  fixa- 
tion without  compression  of  the  fractured  region  except  posteriorly,  allows  the 
patient  to  be  lifted  with  ease,  does  not  interfere  with  the  groin,  favors  cleanli- 
ness, admits  of  traction,  can  be  applied  without  moving  the  patient  and  without 
assistance,  and  presents  no  difficulties  after  the  initial  application  (see  Figs. 

534,  535). 

The  splint  is  made  of  soft  iron,  and  consists  of  a  main  stem,  a  chest  band,  a 
thigh-band,  and  a  calf-band.  The  stem  is  an  inch  and  a  quarter  wide  and 
one-fourth  of  an  inch  thick,  and  in  length  reaches  from  the  axilla  to  the  calf 
of  the  leg — the  length  of  the  lower  portion  from  the  hip-joint  to  the  calf  of  the 
leg  being  equal  to  that  from  the  axilla  to  the  hip-joint.  In  the  part  opposite 
the  buttock  two  gentle  bends  are  made,  the  lower  somewhat  backward  and 
the  upjjer  upward,  so  that  the  body  and  leg  portions  of  the  splint  follow  parallel 


394 


FRACTURES   OF  THE   FEMUR 


lines  from  one-half  to  one  inch  apart,  the  body  portion  being  posterior  to  the 
leg  portion.  The  stouter  the  patient,  the  more  nearly  do  these  parallel  lines 
coincide,  and  in  some  cases  the  main  stem  may  be  felt  entirely  straight.  To 
the  lower  end  is  fastened,  by  one  rivet,  the  calf-band,  one-sixteenth  by  five- 
eighths  of  an  inch,  and  in  length  an  inch  or  two  less  than  the  circumference  of 
the  leg  at  this  point.  The  thigh -band  is  one-sixteenth  by  three-fourths  of  an 
inch,  and  in  length  an  inch  or  two  less  than  the  circumference  of  the  thigh 
at  its  largest  part;  it  is  riveted  to  the  main  stem  just  below  the  lower  bend,  so 
that  when  applied  to  the  patient,  it  comes  well  up  to  the  perineum.  The 
chest-band  is  three-thirty-seconds  by  one  and  one-fourth  inches,  and  in  length 


Fig.  536. — Tracing  of  photograph  of  patient  (see  skiagram^  Fig.  S37)  four  years  after 
fracture  of  the  left  femoral  neck,  showing  the  shortening  and  turning  out  of  the  leg  (after 
Whitman). 


nearly  equal  to  the  circumference  of  the  chest,  being  relatively  longer  than  the 
other  bands.  It  is  fastened  by  one  rivet  after  the  upper  end  of  the  stem  has 
been  forged  flat  and  bent  back  over  it.  This  arrangement  makes  a  fast  joint, 
and  brings  the  stem  between  the  chest -band  and  the  skin.  In  each  end  of  the 
chest -band  a  round  hole  is  forged  of  at  least  one-half  inch  in  diameter. 

Summary  of  material  and  measurements  required  in  making  the  Thomas 
splint  : 

Stem,  I J  inches  wide,  J  inch  thick,  extending  from  the  axilla  to  the  calf  of 
the  leg. 


FRACTURE  OF  THE  HIP — TREATMENT  395 

Calf-band,  f  inch  wide,  re  inch  thick;  the  length  is  two  inches  less  than  the 
circumference  of  the  calf  of  the  leg. 

Thigh-band,  -|  inch  wide,  i\  inch  thick ;  the  length  is  two  inches  less  than  the 
largest  circumference  of  the  thigh. 

Chest-band,  ij  inches  wide,  A  inch  thick;  the  length  to  nearly  equal  the 
circumference  of  the  chest. 

A  hole  is  forged  at  each  end  of  the  chest-band,  I  inch  in  diameter.  Any 
good  blacksmith  can  make  this  splint  in  a  very  short  time. 

The  splint  is  now  bent  to  fit  approximately  the  patient,  padded  on  the  side 
that  is  to  come  next  the  skin  with  a  quarter-inch  thickness  of  felt,  care  being 
taken  to  leave  no  inequalities  of  surface,  and  then  covered  with  basil  leather 
put  on  wet  and  tightly  drawn,  so  that  when  dry  it  will  have  shrunk  sufficiently 
to  prevent  the  cover  from  slipping  on  the  iron.     The  splint  is  applied  by  open- 


Fig.  S37.— Skiagram  tracing  of  patient  two  and  a  half  years  of  age,  after  the  accident, 
illustrating  the  deformity  of  the  neck  and  of  the  upper  extremity  of  the  shaft,  also  the  eleva- 
tion of  the  pelvis  on  the  affected  side  (after  Whitman). 

ing  out  the  wings  of  the  bands  looking  to  the  uninjured  side  of  the  patient,  and 
then  slipping  them,  followed  by  the  stem,  underneath  the  patient  from  the 
injured  side;  the  wings  that  were  straightened  are  bent  again  by  hand  and  read- 
ily return  to  their  former  curves.  A  closer  and  more  accurate  adjustment  of 
the  wings  may  be  made  by  the  use  of  wrenches;  these  will  be  found  especially 
serviceable  in  fitting  the  chest -band  and  in  drawing  in  the  other  bands  when  the 
patient  is  very  intolerant  of  any  threatened  movement  or  jarring. 

"The  splint  having  been  fitted,  if  retentive  traction  is  not  required,  the  limb 
is  bandaged  to  the  stem  from  the  calf  to  the  upper  part  of  the  thigh,  rolling 
the  bandage  in  the  direction  the  opposite  to  the  rotatory  deformity  that  may 
be  present ;  then  shoulder-straps  are  applied  by  taking  a  couple  of  yards  of  broad 
bandage  or  a  strip  of  muslin,  looping  it  round  the  stem  where  it  joins  the  chest- 
band,  then  over  the  band  and  over  the  shoulders,  and  down  to  the  ends  of  the 
chest-band.  Here  it  is  passed  through  the  holes  and  tied;  then  it  is  passed 
across  the  intervening  space  to  the  opposite  hole  and  again  tied.  If  reten- 
tive traction  is  desired,  the  shoulder  straps  are  omitted.  To  each  side  of 
the  limb  from  the  upper  part  of  the  thigh  after  the  limb  has  been  pulled 
down  to  the  splint  a  broad  strip  of  adhesive  plaster  is  applied.     The  lower 


396 


FRACTURES    OF    THE    FEMUR 


ends  of  the  plaster  are  turned  outward  and  upward  around  the  wings  of  the 
calf-band,  where  they  are  fastened  by  a  strip  of  plaster  passed  entirely  around 
the  limb;  the  whole  is  then  covered  with  a  bandage.  By  this  arrangement 
the  limb  is  pulled  upon  only  to  the  extent  of  correcting  the  actual  shortening, 
and  is  held  at  one  and  the  same  length  sleeping  or  waking,  whether  the 
muscles  relaspe  or  are  spasmodically  contracted. 


Fig.  53&- — Tracing  of  photograph  ot  patient  eight  years  old,  some  years  after  a  fracture 
of  the  neck  of  the  right  femur,  showing  great  projection  and  elevation  of  the  trochanter, 
made  more  apparent  by  flexing  the  thigh  and  leg  (Whitman). 

"The  device  aims  to  prevent  motion  in  the  axis  of  the  limb;  to  prevent 
lateral  motion  by  bending  the  limb  in  any  direction;  to  do  this  without  con- 
stricting the  region  of  the  fracture;  and  to  enable  the  patient  to  have  the  bed- 
pan adjusted  without  pain  and  without  disturbing  the  relation  of  the  parts. 
When  the  splint  has  been  applied  and  the  patient  is  in  bed,  the  nurse  should 
be  instructed  in  certain  maneuvers.  The  bed-pan  is  adjusted  by  passing  the 
arm  under  both  limbs  or  below  the  knees  and  then  lifting  directly  upward, 


Head  of  femur. 


Marks  upper  limit  of  head  of  bone. 


Shaft  of 

femur, 

lower 

fragment. 


Fig.  539. —Case  :  Girl  13  years  of  age.     Old   fracture  ol   bhalt  of  femur  with  vicious  union. 
Fresh  fracture  of  neck  of  femur. 


397 


398  FRACTURES   OF  THE   FEMUR 

making  an  incline  of  the  whole  patient  below  the  chest-band.  By  this  man- 
euver it  is  also  more  easy  to  smooth  out  wrinkles  in  the  bedding  and  change 
the  sheet  than  in  the  usual  way.  The  stem  should  be  made  to  press  upon 
different  parts  of  the  skin  by  pulling  the  skin  night  and  morning  first  to  one 
side  and  then  to  the  other.  The  patient  should  be  inspected  daily  for  pressure 
sores  by  turning  him  on  the  sound  side.  In  order  to  turn  a  patient  upon  the 
sound  side  support  the  fractured  limb  at  the  knee  with  one  hand  and  grasp 
the  chest-band  with  the  other;  the  patient  then  is  readily  turned  as  a  whole. 
The  points  most  likely  to  suffer  from  pressure  are  those  at  the  junction  of  the 
thigh-band  and  stem,  the  lower  bend  of  the  stem,  and  the  junction  of  the  stem 
and  chest-band.  Points  pressed  upon  should  be  tightly  dressed  with  flexible 
collodion  and  protected  from  further  pressure  by  padding  above  and  below. 
If  the  pressure  of  the  Avhole  body  portion  of  the  stem  is  complained  of,  a  small, 
thin,  mattress  of  hair  or  a  sheet  folded  to  several  thicknesses  may  be  placed 
between  the  splint  and  the  patient's  back.  Threatened  hypostatic  congestion 
is  obviated  by  raising  the  head  of  the  bed  from  one  to  three  feet,  the  patient 
meanwhile  being  prevented  from  slipping  down  by  tying  the  splint  to  the  head 
of  the  bed.  In  all  cases  obviously  unimpacted  and  in  all  cases  when  the  short- 
ening is  more  than  three-fourths  of  an  inch,  traction  should  be  applied. 

"In  all  cases  the  splint  should  be  kept  on  for  from  six  to  eight  weeks  after 
all  pain  has  ceased ;  then  the  patient  should  remain  in  bed  four  weeks  longer 
without  any  treatment  whatever,  unless  there  is  some  positive  indication  to 
the  contrary,  in  which  case  the  splint  is  cut  off  at  the  knee  and  the  calf-band 
riveted  at  this  point  and  the  patient  permitted  to  go  about  with  crutches." 

In  addition  to  the  use  of  the  Thomas  splint,  it  may  be  wise  to  make  lateral 
pressure,  as  suggested  by  Senn,  over  the  trochanter  of  the  broken  hip,  with  the 
expectation  of  more  firmly  fixing  the  broken  bone.  Lateral  pressure  may  be 
secured  by  a  surcingle  or  by  a  bandage  applied  over  a  graduated  compress. 
The  spot  to  which  pressure  is  applied  should  be  carefully  watched  and  protected 
lest  a  pressure-sore  appear. 

The  Third  Method. — Forcible  abduction  and  immobilization 
with  or  without  traction  {Whitmans  method). — Fracture  of  the 
neck  of  the  femur  occurs  in  childhood,  in  young  adult  life,  and 
in  old  age  (over  sixty).  It  occurs  more  frequently  in  adult  life  and 
in  childhood  than  is  generally  supposed.  It  has  generally  been 
thought  unwise  to  break  up  an  impacted  fracture  of  the  hip  in 
an  adult  for  fear  of  non-union.  Consequently,  when  treated  by 
the  first  extension  method  or  by  the  second  immobilization 
method  no  especial  attempt  has  been  made  to  reduce  the  de- 
formity attending  the  fracture  (shortening  and  eversion  or  inver- 
sion), and  this  may  be  considerable.  The  limb  has  been  simply 
immobilized.  The  fundamental  principle  underlying  the  treat- 
ment of  all  other  fractures  (viz.,  reduction  of  the  fracture  even  to 
the  breaking  up  of  impaction)  has  been,  in  the  case  of  this  hip 
fracture,  ignored.     Mtich   pain   and    many  disabled    hips    result 


FRACTURE    OF    THE    HIP — TREATMENT 


399 


because  of  deformity.  Whitman  has  recently  suggested  and  ex- 
tensively employed  the  following  method  of  reduction  and  main- 
tenance of  reduction  in  these  cases: 


Fig.  54°  ■ — Section  of  a  hip-joint.  The  dotted  outline  illustrates  limitation  of  the  range  of 
normal  abduction  by  contact  of  the  outer  border  of  the  neck  with  the  upper  border  of  the  acetabulum 
and  of  the  trochanter  with  the  tissues  covering  the  side  of  the  pelvis  (Fick). 


Fig.  541- — Impacted  fracture  of  the 
neck  of  the  femur,  illustrating  the  limi- 
tation of  abduction  caused  by  the  de- 
formity (Whitman). 


Fig.  542. — Illustrates  the  restoration  of  the  normal  angle 
by  forcible  abduction  (Whitman). 


Method  of  Abduction  {Whitman's  Method)  Based  upon  the  Fol- 
lowiug  Facts. — The  normal  abduction  of  the  hip  is  limited  by  the 
contact  of  the  great  trochanter  with  the  tissues  above  the  acetab- 


Fig.  543- — Impacted  fracture  of  the  neck  of  the  right  femur,  illustrating  the  reduction  of  the 
deformity  by  direct  traction  and  abduction.  The  operator  supports  the  joint.  The  left  limb  is  ab- 
ducted to  indicate  the  normal  range,  which  varies  in  difierent  subjects,  and  to  prevent  tilting  of  the 
pelvis  (Whitman). 


Fig.  544- — The  long  spica  as  applied  for  the  treatment  of  fracture  of  the  neck  of  the  femur  in  the  adult 

at  an  angle  of  abduction  of  45  degrees  (Whitman). 

400 


fracture;  of  the  hip — treatment 


401 


ulum.  When  the  hmb  is  normally  abducted  the  under  part  of  the 
capsule  is  rendered  taut  and  tends  to  retain  the  broken  neck  or 
head  in  normal  relations,  while  the  abducted  position  itself  helps 
to  force  the  broken  neck  more  and  more  into  its  natural  relations. 
In  an  impacted  fracture  the  abducted  position  serves  to  reduce 


Fig-  545.— Fracture  of  the  neck  of  the  femur.  A  double  spica  bandage  of  plaster-of -Paris  applied 
under  an  anesthetic.  The  thigh  slightly  flexed,  abdticted  with  traction.  X,  rod  of  plaster  holding 
thigh  steady;  Z,  splint  extends  to  knee  only;  Y,  injured  leg  splint  extends  to  ankle  or  includes  whole 
foot;  W,  body  or  pelvic  portion  of  splint. 


deformity  without  altogether  separating  the  fragments  and  com- 
pletely breaking  up  the  impaction.  In  complete  and  unimpacted 
fractures  the  abducted  position  adjusts  the  fragments  and  fixes 
them   (see  Figs.   540-549). 

Method  of  Using  the  Abduction  Method. — The  patient  is  anesthet- 
26 


402 


FRACTURES    OF   THE    FEMUR 


ized,  the  pelvis  supported  from  off  the  table.  The  well  limb  is 
abducted  to  the  extreme  in  order  to  steady  the  pelvis.  Then  the 
injured  limb,  while  supported,  is  abducted  while  traction  is  being 
made  to  the  normal  (45  °)  position. 

If  the  hip  is  impacted  at  the  seat  of  fracture  I  believe  that  it  is 
wise  under  the  anesthetic  to  overcome  the  deformity  incident  to 
the  impaction  by  carefully  separating  and  unlocking  the  impaction. 
This  can  be  done  with  gentleness,  not  by  tearing  and  ripping 


Fig.  546. — Same  as  Fig.  545,  a  frout\-ie\v.  If  the  splint  of  plaster  is  carefully  applied  it  is  a  most 
Comfortable  splint  and  not  a  tedious  position  for  convalescence.  The  thighs  cannot  always  be  so  much 
permanently  flexed.     Legs  are  suspended  just  to  clear  bed. 


apart  violently  and  harshly,  but  by  intelligently  opening  the  frag- 
ments as  one  opens  a  hinge.  In  the  young  adult  breaking  up  the 
impaction  will  often  be  wise.  In  certain  elderly  individuals  it 
may  not  be  best  to  disturb  the  impaction.     If  the  fracture  is  unim- 


FRACTURE    OF   THE    HIP — TREATMENT  403 

pacted  the  limb  should  be  made  by  traction  to  equal  its  fellow  in 
length  before  abduction  is  attempted. 

If  the  fractured  limb  is  abducted  before  the  shortening  is  cor- 
rected the  fragments  will  be  separated,  if  after  the  shortening  is 
corrected,  the  fragments  will  be  opposed. 

The  plaster-of-Paris  support  is  now  applied  to  pelvis  and  thigh, 
including  the  foot  in  young  adults  and  children.  In  adults  the 
plaster  spica  need  extend  only  to  the  middle  of  the  calf  of  the  leg. 


Fig.  547- — The  short  spica  applied  to  fix  the  limb  in  the  abducted  position,  showing  the  method  of 
moulding  it  about  the  plevis  and  knee  to  assure  fixation  (Whitman). 

The  trochanter  should  be  lifted  forward  from  the  table  to  over- 
come any  sagging  backward.  It  may  be  wise  in  some  cases  to 
flex  the  thigh  (Maxwell)  in  order  to  the  more  readily  reduce  the 
fragments.  Traction,  abduction,  flexion,  lifting  the  trochanter 
forward,  rotation  (to  correct  abnormal  e version  or  inversion  of 
the  foot),  immobilization — these  are  the  steps  of  the  proce- 
dure. 

Cases  must  be  selected  with  care  for  this  treatment,  viz.,  those 
which  can  be  subsequently  held  in  a  plaster  dressing  comfortably, 
those  in  which  the  manipulation  described  is  likely  to  correct  the 
deformity.  More  and  more  cases  are  being  treated  by  the  ab- 
duction and  immobilization  method.  This  method  has  come  to 
stay. 


Fig-  548. — The  short  (Lorenzl  spica,  illustrating  the  perineal  band  which  prevents  movement  of  the 
pelvic  portion  of  the  spica  (Whitman). 


Fig.  549. — The  short  plaster  spica,  combined  with  traction  (Whitman). 
404 


Upper  femoral 
epiphysis 


FiS-  550- — Separation  of  the  upper  epiphysis  of  the  femur.  Note  epiphysis  separated  and  dis- 
placed so  as  to  rotate  the  femur  inward,  corresponding  to  the  photograph  of  the  attitude  of  this  patient 
(see  Fig.  SSs).  Absence  of  the  lesser  trochanter  demonstrates  the  rotation  of  femur  inward  (see  Fig. 
551,  Mumford). 


Upper  femoral 
epiphysis 


Fig.  SSI.— Separation  of  the  upper  epiphysis  of  the  femur.     After  reduction  by  traction, 
femoral  epiphysis  in  normal  place. 

405 


Note 


4o6 


FRACTURES   OF  THE   FEMUR 


The  plaster  spica  is  kept  in  place  about  eight  weeks.  The 
body  weight  should  not  be  allowed  to  fall  on  the  fractured  neck 
for  several  weeks  after  this.  A  Taylor  hip  splint  or  high  shoe  and 
crutches  with  dangling  leg  should  be  insisted  upon  to  avoid 
subsequent  pain  and  disability,  which  too  often  follows  early 
use  of  the  leg. 

The  Fourth  Method. — Operative  Method  of  Pegging  the  Frac- 


Fig.  552  .• — Separation  of  the  upper  femoral  epiphysis  in  a  child  (see  Figs.  55°i  SSi).  Note  the  deformity 
as  that  of  a  dislocation  of  the  hip  on  the  dorsum  of  the  ilium.   Flexed  and  adducted  thigh,  flexed  knee. 


ture. — This  operative  method  is  to  be  reserved  for  those  fractures 
occurring  in  well  adults  who  cannot  properly  be  treated  success- 
fully by  the  other  methods.  In  fresh  fractures  in  old  people  and 
young  adults  a  peg  may  be  placed  without  a  skin  incision  directly 
through  the  trochanter  and  neck  into  the  head.  In  old  ununited 
fractures  of  the  hip  in  which  it  is  reasonable  to  suppose  that 
the   bony   surfaces  need   refreshing  or   in   which  there  may  be 


407 


4o8  FRACTURES    OF   THE    FEMUR 

adventitious  bony  material  to  be  removed,  an  incision  should 
be  made.  By  an  incision  the  interior  of  the  joint  and  the  seat 
of  fracture  will  be  rendered  accessible;  the  procedures  of  re- 
freshing the  fractured  surfaces  and  pegging  will  be  facilitated. 
The  incision  of  choice  is  a  straight  one  to  the  outer  side  of  the 
tensor  vaginae  femoris  muscle.  After  the  wire  nail  or  drill  is 
placed  the  wound  is  closed  without  drainage.  The  peg  is  left 
permanently  or  it  may  be  removed  about  four  weeks  subse- 
quently. 

After  pegging,  the  hip  is  best  immobilized  by  the  plaster-of- 
Paris    dressing    applied    in    the   abducted    position  (see   p.   404, 

Fig-  549)- 

In  the  actual  operation  of  pegging,  the  limb  is  extended  to 
equal  the  length  of  its  fellow,  and  abducted  sufficiently  to  approx- 
imate the  fragments.  The  nail,  about  6  in.  long,  is  entered  one- 
half  inch  from  the  anterior  edge  of  the  great  trochanter  and  two 
fingers'  breadth  from  the  top  of  the  great  trochanter,  directed 
upward  and  inward,  making  an  angle  with  the  femoral  shaft  of 
about  seventy  degrees.  The  nail  is  driven  or  pushed  in  through 
the  head  fragment;  the  surface  of  the  acetabulum  had  best  not 
be  penetrated.     An  X-ray  taken  after  pegging  will  be  useful. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood. — Whitman 
has  called  especial  attention  to  this  fracture.  The  anatomical 
proof  of  the  existence  of  fracture  of  the  neck  of  the  femur  in 
childhood  has  been  furnished  by  the  specimens  of  Bolton,  Meyers, 
and  Starr,  and  by  many  X-ravs.  The  fracture  occurs  after  trau- 
matism to  the  hip  probably  more  frequently  than  separation  of 
the  upper  femoral  epiphvsis.  It  is  not  so  uncommon  an  accident 
as  has  been  supposed.  The  fracture  is  probably  impacted  or  green- 
stick.  The  clinical  picture  of  fracture  of  the  neck  of  the  femur 
in  childhood  differs  greatly  from  that  furnished  by  a  similar  in- 
jury in  old  age.  In  the  first  instance  a  healthy  child  falls  from  a 
height,  and  presents  a  shortening  of  the  thigh  of  from  one-half  to 
three-quarters  of  an  inch.  There  are  slight  outward  rotation  of 
the  leg  and  limitation  of  motion  and  sHght  discomfort  in  the 
hip.  The  child  may  walk  about  after  a  few  days  with  but  a 
little    lameness   to    suggest  that  any  injury   has   been   received. 


FRACTURE    OF    NECK    OF    FEMUR    IN    CHILDREN  409 

The  child  recovers  with  a  Hmp.  Months  or  years  later  signs 
of  coxa  vara  appear.  In  childhood  a  rather  severe  injury  is 
followed  by  immediate  symptoms,  and  later  by  great  disability. 
On  the  other  hand,  in  old  age  a  trivial  injury  is  followed  by  im- 
mediate and  complete  disability.  It  is  often  overlooked  in  the 
child  and  is  treated  for  a  contusion  or  sprain  of  the  hip. 

The  immediate  result,  however,  is  extremely  good  even  without 
more  than  bed  treatment,  but  the  ultimate  result  after  several 
months  or  years  may  be  disastrous  because  of  the  disability  due  to 
a  gradually  increasing  bending  of  the  femoral  neck.  The  late 
result  of  fracture  of  the  femoral  neck  in  childhood  resembles  hip- 
disease  in  the  limp,  slight  pain,  shortening,  deformity,  and  hmita- 


Fig.  557.— Fracture  of  the  thigh  at  the  middle.     Characteristic  deformity. 

tion  of  motion  present.  Care  must  be  taken  not  to  confound  the 
two  conditions.  These  later  stages  of  fracture  are  to  be  treated 
by  rest  to  the  joint.  All  body-weight  and  the  jar  of  walking 
are  to  be  removed  by  a  properly  fitting  hip-splint  with  traction. 
Refracture  and  operative  measures  are  to  be  seriously  entertained, 
as  in  other  forms  of  coxa  vara,  particularly  if  the  disability  is 
great  or  is  increasing  (see  Figs.  538,  553-556  inclusive). 

The  treatment  of  a  fresh  greenstick  or  impacted  fracture  of  the 
hip  in  children  should  be  by  rest  on  the  back  in  bed  and  moderate 
traction  and  immobilization  of  the  hip  and  thigh  and  body. 
If  there  be  deformity   (shortening,   eversion  or  inversion)   then 


4IO 


FRACTURES    OF   THE    FEMUR 


the  forcible  abduction  and  plaster-of-Paris  immobilization  are 
required  as  in  adults.  After  a  month  the  child  may  be  allowed  up, 
wearing  a  traction  hip-splint  for  several  months  until  union  is  so 
firm  that  the  danger  from  coxa  vara  is  practically  eliminat  d. 
A  light  plaster-of-Paris  spica  bandage  from  calf  to  axilla  will 
maintain  immobility  after  the  splint  is  omitted. 

FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR 

Fracture  of  the  shaft  of  the  femur  is  usually  oblique.     It  is 
situated  either  just  below  the  lesser  trochanter  (subtrochanteric 


Fig.  558. — Fracture  of  the  right  femur  at   the   middle.     Characteristic   deformity.     Inward 
rotation  of  leg  below  fracture. 


fracture),  at  the  center  of  the  shaft,  or  above  the  condyles) 
(supracondyloid  fracture).  Even  in  closed  fractures  there  is 
sometimes  great  damage  to  the  soft  parts:  the  vessels  of  the 
thigh  are  at  times  injured. 

Symptoms. — There  is  often  great  swelling  at  the  seat  of  frac- 
ture. The  limb  lies  helpless.  Pain,  abnormal  mobility,  de- 
formity, marked  rolling  of  the  leg  below  the  seat  of  the  frac- 
ture, and  crepitus,  one  or  all,  may  be  evident  (see  Figs.  557, 
558).     The  limb  is  shortened. 

Measurement  (see  Figs.  565-569  inclusive)  to  determine  the 
amount  of  the  shortenings  is  to  be  made  from  the  anterior  superior 


Fig.  559- 


Fig.  s6o. 


Fig.  561. 


Fig.  s')-'. 


Fig.  563.  Fig.  564. 

Figs.  559-564. — Fracture  of  the  shaft  of  the  femur.     Types  of  fracture. 
411 


412 


fracture;  of  the  femur 


spinous  process  of  the  ilium  to  the  internal  malleolus  of  the 
same  side.  Great  care  must  be  exercised  in  taking  this  measure- 
ment so  that  the  patient  lies  flat  upon  the  back  upon  a  hard  and 
even  surface,  with  the  arms  at  the  sides  of  the  body  and  with 
no  pillow  under  the  head  or  shoulders.  The  long  axis  of  the 
body  should  be  in  the  same  line  with  the  long  axis  between  the 
legs  as  they  lie  with  the  malleoH  approximated — i.  e.,  the  chin, 


Fig-  565. — Fracture  of  the  thigh.     Correct  method  of  measurement  from  the  anterior  superior 
spinous  process  of  the  iHum.     Position  of  thumb  and  finger  holding  tape. 


Fig.  566. — Measuienicut  of  lower  extreniit\.     I'osiUon  of  thumbs  bhown.     Note  position  of 

limb. 

episternal  notch,  umbilicus,  the  symphysis  pubis,  the  midpoint 
between  the  knees,  and  the  midpoint  between  the  internal  mal- 
leoli should  all  be  in  one  straight  line  (see  Fig.  569).  The  line 
joining  the  anterior  superior  spinous  processes  of  the  ilia  should 
be  at  right  angles  to  this  long  axis  of  the  body  and  thighs.     Any 


i^racture;  of  shaft  of  femur — treatment 


413 


variations  from  this  normal  position  are  attended  by  errors  in 
measurement,  which  are  important.  If  for  any  reason  the  in- 
jured thigh  can  not  be  brought  easily  alongside  its  fellow,  the 
two  limbs  should  be  placed  as  nearly  symmetrical  with  reference 
to  the  median  line  as  possible. 

The  method  of  measuring  the  lengths  of  the  lower  extremities 
used  by   Dr.  Keen  differs  from   the  above  in  that  he  uses  the 


Fig.  567. — Measurement  of  lower  extremity. 
Patient  lying  on  the  back  looked  at  from  above. 
Position  of  tape,  hands,  and  limbs  to  be  noted. 


Fig.  568. — \iiie  lliat  normally  a 
line  from  the  anterior  superiorspinous 
process  of  the  ilium  through  the  center 
of  the  patella  touches  the  inner  side  of 
the  inner  malleolus. 


malleolus  as  the  fixed  point,  and  measures  to  a  line  drawn  at 
the  anterior  superior  spinous  processes  of  the  ilium.  The  finger 
and  tape  are  not  allowed  to  touch  the  skin-mark,  and  so  do  not 
displace  it. 

Treatment  of  Fracture  of  the  Shaft  of  the  Femur.— The 
Transportation  of  a  Patient:  The  emergency  method  of  putting 
up  a  fracture   of  the  thigh  or  hip  is  of  very  great  practical  ira- 


414 


FRACTURKS   OF  THE   FEMUR 


portance  (see  Fig.  570).  Limbs  are  fractured  frequently  some 
distance  from  the  proper  place  for  the  application  of  the  per- 
manent dressing.     It  is  necessary  to  transport  such  cases  with 


Fig.  569- — Measurement  of  the  length  of  the  lower  extremity.  Patient  represented  lying 
on  back,  looked  at  from  above.  The  line  joining-  the  anterior  superior  spinous  processes  of 
ilia  (C,£>)  should  be  at  right  angles  to  the  long  axis  of  the  body  {A,  B).  In  this  position  only 
can  comparable  measurements  be  made.     (Drawn  by  C.  Rimmer.) 


the  greatest  degree  of  safety  and  comfort.  In  order  to  accom- 
plish this  the  knee-  and  hip- joints  should  be  extended,  the  leg 
being  held  straightened  in  the  long  axis  of  the  body.  The  limb 
should  be  placed  upon  a  heavily  padded  board,  the  width  of  the 
thigh,  extending  from  the  middle  of  the  calf  to  above  the  sacrum. 


FRACTURE  OF  SHAFT  OF  FEMUR — TREATMENT       415 

The  side  splints  of  wood  should  be  used — one  on  the  outer  side 
extending  from  the  side  of  the  foot  to  the  axilla,  the  other  upon 
the  inner  side  extending  from  the  side  of  the  foot  to  a  few  inches 
below  the  perineum.  Upon  the  front  of  the  thigh  is  placed  a 
coaptation  splint  extending  from  the  groin  to  the  patella.  All 
of  these  splints  are  carefully  padded,  preferably  with  folded 
sheets  or  pillow-cases  or  towels;  of  course,  in  emergency  work 
small  pillows  or  coats  or  shawls  may  be  utilized.  It  is  important 
that  the  padding  be  evenly  and  intelligently  arranged.     It  will 


Fig.  570. — Fracture  of  hip  or  thigh.     Emergency  apparatus. 


Fig.  571- — Fracture  of  the  'thigh.     Method  of  holding  leg  in  order  to  detect  fracture  of  the 
thigh.     Pelvis  is  steadied  by  an  assistant. 

be  necessary  to  place  a  wide  pad  between  the  upper  end  of  the 
long  outside  splint,  to  prevent  it  from  pressing  upon  the  ribs 
and  side  of  the  chest  and  causing  great  discomfort.  These 
splints  are  held  in  position  about  the  leg,  while  gentle  traction 
is  being  made  upon  the  limb,  by  straps  or  pieces  of  bandage 
placed  above  the  ankle,  below  the  knee,  above  the  knee,  at  the 
middle  of  the  thigh,  and  at  the  level  of  the  perineum,  The 
upper  end  of  the  long  outside  splint  is  held  to  the  side  by  a 
swathe  about  the  body  and  splint.  The  patient  should  then  be 
carefully  placed  upon  a  stretcher  (a  Bradford  frame  is  an  ideal  form 


4i6 


FRACTURES   OF   THE   FEMUR 


of  stretcher)  improvised  for  the  occasion.  With  this  apparatus 
snugly  appHed,  the  patient  may  be  securely  and  comfortably 
transported. 

The  objects  of  treatment  are  to  reduce  the  fracture,  to  main- 
tain the  reduction  immobilized  until  union  is  firm,  and  to  restore 
the  leg  to  its  normal  usefulness.  In  the  treatment  of  two  of  the 
three  varieties  of  fracture  of  the  femur  permanent  traction  upon 


Fig.  572. — Pulley  arranged  on  broom-haiKlle  to  be  fastened  at  foot  of  bed  for  carrying  exten- 
sion cord. 


the  lower  fragment  and  permanent  countertraction  upon  the 
upper  fragment  are  necessary. 

The  patient  with  a  fractured  thigh  should  always  be  anes- 
thetized before  putting  the  thigh  up  permanently.  Never 
anesthetize  the  patient  until  all  the  different  parts  of  the  apparatus 
are  ready  and  on  a  table  near  the  bed  of  the  patient.  Always 
put  the  thigh  up  in  temporary  dressings  until  all  is  prepared  for 
the  permanent  splints.  About  one  hour  will  be  consumed  in 
applying  the  extension  apparatus  after  the  patient  is  anesthe- 
tized. There  will  be  no  harm  in  letting  the  patient  rest  com- 
fortably in  the  temporary  splints  over  one  night  until  all  neces- 
sary arrangements  have  been  made  for  the  permanent  dressing. 

Method  of  Examination:  The  patient  is  completely  anesthe- 


FRACTURE    OF    SHAFT   OF   FEMUR — TREATMENT 


417 


tized  in  order  to  secure  muscular  relaxation.  Accurate  exam- 
ination is  now  made  of  the  fracture.  If  the  ends  of  the  frag- 
ments lie  close  to  the  skin,  great  care  must  be  exercised,  by 
steadying  the  thigh,  to  prevent  them  being  pushed  through  the 
skin  and  thus  rendering  the  fracture  an  open  one.  An  assistant 
should  steady  the  pelvis  and  upper  thigh  (see  Fig.  571).  The 
surgeon  should  grasp  the  thigh  above  the  condyles  with  both 
hands,  and  should  make  traction  in  the  axis  of  the  limb.     He 


Fig-  573- — Fracture  of  the  shaft  of  the  femur.  The  fragments  cannot  be  brought  into  exact  appo- 
sition by  simple  longitudinal  traction,  consequently  note  lateral  traction  being  made  both  externally 
and  internally  by  broad  straps  and  weight  and  pulley.  The  two  side  splints,  coaptation  splints,  traction 
being  made  in  long  axis  of  limb,  swathe  about  long  outside  splint  and  body,  are  all  seen  in  the  figure. 


then  determines  the  pull  necessary  to  be  exerted  to  hold  the 
fragments  reduced.  While  this  pull  is  maintained  by  an  assist- 
ant, the  surgeon  manipulates  the  thigh  in  order  to  learn  with 
what  ease  or  difficulty  the  fragments  may  be  held  in  position. 

Traction  in  the  long  axis  of  the  leg  may  not  correct  all  lateral 
displacement.  Traction  applied  at  right  angles  to  the  long  axis 
of  the  leg  over  the  side  of  the  bed  will  assist  materially  in  reducing 
lateral  displacement  (see  Fig.  573). 

In  adults  in  fracture  of  the  middle  of  the  shaft  of  the  femur, 
27 


4i8 


FRACTURE  OF  SHAFT  OF  FEMUR — TREATMENT      419 

traction  and  immobilization  are  best  maintained  by  a  modified 
Buck's  extension  apparatus.  Materials  needed  for  a  modified 
Buck's  extension:  Two  strips  of  adhesive  plaster,  each  two  inches 
wide  and  long  enough  to  extend  from  the  seat  of  fracture  to  the 
internal  malleolus.  Surgeon's  adhesive  plaster  is  nonirritating 
to  the  skin,  and  is  prepared  in  rolls  of  convenient  width.  To 
each  strip  of  plaster  at  the  ankle  end  should  be  stitched  a  piece 
of  webbing  the  width  of  the  plaster  and  about  six  inches  long. 
Prepare  five  other  strips  of  adhesive  plaster,  all  of  which  should 
be  one  and  a  half  inches  wide.  Three  of  these  strips  should 
be  long  enough  to  encircle  respectively  the  leg  above  the  mal- 
leoli, the  knee  above  the  condyles,  and  the  thigh  an  inch  below 
the  seat  of  the  fracture.  The  remaining  two  strips  of  plaster 
should  be  long  enough  to  extend  spirally  from  the  malleoli  around 
the  leg  and  thigh  to  the  seat  of  fracture.  Prepare  also  a  roller 
bandage  of  gauze  or  cotton  cloth,  a  curved  or  straight  ham-splint 


Fig.  575- — Pulley  arranged  for  bed. 


properly  padded,  and  three  adhesive  straps  for  holding  the  ham- 
splint. 

In  addition,  three  coaptation  splints  for  surrounding  the  thigh 
are  required,  also  six  webbing  straps  with  buckles  or  strips  of 
bandage  to  be  used  as  straps;  fresh  sheets  or  pillow-cases  or  towels 
for  padding;  a  swathe,  to  encircle  the  pelvis,  made  of  unbleached 
cotton  cloth  or  medium  weight  Shaker  flannel ;  and  a  long  outside 
splint  of  wood,  four  inches  wide,  to  extend  from  the  axilla  to  six 
inches  below  the  sole  of  the  foot.     To  this  last  a  cross-piece, 


420 


FRACTURES    OF    THE    FEMUR 


eighteen  inches  long,  should  be  fastened,  making  thus  a  long 
T-splint.  The  list  is  completed  by  two  toivels  for  perineal  straps, 
safety-pins,  a  pulley,  which  can  be  bought  at  little  cost  at  any 
hardware  store  (see  Fig.  572).  This  pulley  should  be  screwed 
into  a  broom-handle  cut  to  the  right  height.  A  block  with  hooks 
above  and  a  pulley  below  will  sometimes  be  found  to  be  more 
convenient  than  the  broom-handle  arrangement  (see  Fig.  575). 
A  spreader  (see  Fig.  576),  which  is  a  piece  of  wood  two  inches 
wide  and  a  little  longer  than  the  width  of  the  foot,  perforated 
at  its  center  for  the  extension  v.eight  cord.  There  should  be 
provided  a  cord,  three  feet  long,  size  of  a  clothes-line;  two  bricks 
or  wooden  blocks  for  elevating  the  foot  of  the  bed ;  four  sand-bags, 
twenty  inches  long  and  six  inches  wide;  a  cradle  (see  Fig.  577) 


Fig.  576. — Spreader  of  wood  for  preventing  extension  straps  trom  chafing  ankle  and  foot. 
Cord  for  attaching  weight. 


to  keep  the  weight  of  the  clothes  from  the  thigh — the  cradle 
may  be  a  chair  tipped  up,  or  barrel-hoops  nailed  together. 

Application  of  the  Modified  Buck's  Extension. — All  the  materials 
being  in  readiness  and  at  hand,  the  patient  having  been  etherized 
and  the  fracture  examined,  the  thigh  and  leg  and  foot  are  first 
washed  with  warm  water  and  Castile  soap  and  thoroughly  dried. 


FRACTURB  OF  SHAFT  OF  FEMUR — TREATMENT      42 1 

The  long  straight  strips  of  adhesive  plaster  with  the  webbing 
attached  are  applied  to  the  middle  of  the  two  sides  of  the  leg 
and  thigh  up  to  the  seat  of  fracture.  The  junction  of  the  ad- 
hesive plaster  and  webbing  should  be  brought  to  just  above  the 
malleoli.  The  two  spiral  and  then  the  three  circular  strips 
should  next  be  applied  as  indicated  (see  Fig.  578).  Over  the 
extension  is  placed  a  roller  bandage,  snugly  and  evenly  inclosing 
the  foot.  The  bandage  steadies  the  adhesive  plaster,  prevents 
swelling  of  the  foot,  and  affords  comfort.  Then  the  padded 
posterior  coaptation  or  ham-splint  is  applied  and  held  by  three 
straps  of  adhesive  plaster,  one  at  each  end  of  the  splint  and  one 
below  the  knee  (see  Fig.  579).  If  the  curved  ham-splint  is  used, 
the  padding  (one  sheet  of  sheet  wadding)  should  be  laid  upon 
the  splint  evenly  throughout.  If  a  straight  ham-splint  is  used, 
the  padding  should  be  applied  evenly,  and  at  the  middle  of  the 
ham,  behind  the  knee,  should  be  placed  an  additional  pad  (see 


Fig.  577. — Bed-cradle.     Can  be  made  of  barrel  hoops. 

Fig.  580)  in  order  to  support  the  knee  in  its  natural  position. 
This  additional  pad  should  be  placed  between  the  splint  and  the 
layer  of  sheet  wadding.  The  tendency  of  the  padding  of  the 
ham-splint  is  to  slip  away  from  each  end  of  the  splint  and  thus 
leave  it  unduly  pressing  into  the  thigh  and  calf.  It  is  wise  to 
hold  this  padding  in  place  by  strips  of  adhesive  plaster  at  each 
end  of  the  splint.  The  three  thigh  coaptation  splints  should 
be  next  put  in  position — one  anteriorly,  extending  the  whole 
length  of  the  thigh  from  groin  to  patella ;  one  externally,  extend- 
ing from  trochanter  to  external  condyle;  and  one  internally,  ex- 
tending from  just  below  the  perineum  to  just  above  the  adductor 
tubercle  (see  Fig.  580).  The  best  padding  for  these  splints  is  a 
towel  folded  the  length  of  the  splints  and  placed  evenly  about 


Fig-  578. — Fracture  of  the  thigh.     Adhesive-plaster  extension  strips ;  long,  upright,  circular, 
and  obliquely  applied  strips. 


Fig.  579- — Fracture  of  the  thigh.     Extension  strips  applied,  covered  by  bandage.     Ham-splint 
applied;  two  straps  and  pad  in  ham. 


Fig.  580. — Fracture  of  the  thigh.     Extension  strips  applied.     Cotton  bandage.     Ham-splint, 
straps,  pad,  and  coaptation  splintr,  about  the  seat  of  fracture.     Straps  and  buckles. 

422 


fracture;  of  shaft  of  femur — treatment 


423 


the  thigh.  These  spHnts  are  held  by  an  assistant  while  three 
or  four  straps  are  tightened  sufficiently  to  hold  them  firmly 
in  place.     While  these  coaptation  splints  are  being  applied  it  is 


Fig.  581. — Fracture  of  the  thigh.     Completed  apparatus  as  in  figure  580,  and  in  addition  a  long 
outside  T-splint,  straps,  and  swathe.     Weights  applied. 


Fig.  582. — Fracture  of   the  thigh.      Completed  apparatus   with  bed  elevated.      The  outside 
splint  is  broad  and  without  the  T  foot-piece.     The  swathe  is  very  snuglj'  applied. 


Fig.  583- — A  fracture  of  the  femoral  shaft,  so  placed  between  two  long  side  splints  and  anterior  and 
posterior  coaptation  splints  with  a  swathe  about  the  body  that  transportation  is  possible  with  a  minimum 
of  discomfort  and  danger  of  damage. 

very  important  that  steady  traction  be  made  upon  the  lower 
fragment  in  order  to  maintain  its  reduction.  The  straps  of  the 
coaptation  splints  are  then  finally  tightened.  The  long  outside 
splint   with   the   T  cross-piece   is   then    padded  with  sheets  and 


424 


FRACTURES    OF    THE    FEMUR 


applied  to  the  side  of  the  limb  and  the  body  (see  Fig.  581).  The 
upper  end  of  the  splint  is  inclosed  in  a  swathe,  which  passes 
around  the  body  and  is  fastened  with  safety-pins.      The  thigh 


Fig.  584.— Form  of  stirrup  to  prevent  the  foot  assuming  an  equinus  position. 


Fig.  585.  Fig.  586. 

Figs.  58s,  586. — Diagram  of  section  of  leg  and  spliBt  to  show  how  a  strap  carried  from  the  back  of 

the  leg  over  the  long  side-splint  can  prevent  e version  of  the  foot  and  leg, 

and  leg  are  held  steadily  to  the  outside  splint  by  two  or  three 
straps  (see  Fig.  582).  The  assistant,  making  extension,  exchanges 
his  traction  for  that  of  the  w^eight  and  pulley.  The  foot  of  the 
bed  is  raised  upon  blocks  or  bricks,  in  order  to  provide  the  coun- 


Fracture  of  shaft  of  femur — treatment. 


425 


ter-extension  by  means  of  the  weight  of  the  body.  The  heel  is 
protected  from  undue  pressure  by  a  ring.  The  foot  is  kept  at 
a  right  angle  with  the  leg  (see  Fig.  584).  The  sand-bags  are 
laid  along  the  inner  and  outer  sides  of  the  limb  to  add  greater 
steadiness  to  the  apparatus.  The  cradle  is  placed  over  the 
foot  and  leg. 

Throughout  the  course  of  the  treatment  of  a  fracture  of  the 
thigh  it  is  necessary  to  be  positive  of  four  things :  (a)  The  absence 
of  shortening  in  the  injured  thigh ;  (b)  the  prevention  of  outward 
bowing  of  the  thigh;  (c)  the  prevention  of  permanent  rotation 


1 '. 

,' 

^ 

',  f 

U    ; 

/                    i 

/ 

1^  ' 

! 

^'  :^ 

- 

-  ■"  -''ii 

-       .v,J^>-^ 

Fig.  587. — The  more  usual  deformities  in  fracture  of  tlie  shaft  of  the  femur.     Outward  and 

posterior  bowing. 


of  the  leg  and  lower  thigh  outward  below  the  seat  of  fracture; 
and  finally  {d),  the  prevention  of  a  sagging  backward  of  the  thigh 
at  the  seat  of  fracture,  causing  what  appears  on  standing  as  a 
false  genu  recurvatum. 

(a)  The  shortening  of  the  injured  leg  is  prevented  by  a  suffi- 
ciently heavy   weight   for  extension.     This   weight  can   be  ap 
proximately    but    not    accurately    determined.     Ordinarily,    in 
an  adult  fifteen  or  twenty  pounds  are  needed  to  hold  the  frag- 
ments  in    proper   position.     Comparative    measurement    of   the 


426 


FRACTURES    OF   THE    FEMUR 


legs  from  the  anterior  superior  spinous  process  to  the  malleolus 
should  be  made  regularly  every  other  day,  and  the  measurements 
recorded  during  the  first  two  weeks  of  immobilization  and  the 
extension  weight  correspondingly  adjusted. 

{b)  In  order  to  prevent  any  outward  bowing  of  the  thigh,  the 
thigh  and  leg  should  be  slightly  abducted    after  the  apparatus 


Fig.  588. — Showing  the  necessity  of  abducting  the  injured  leg  in  thigh  fracture.     In  dotted  line  is 
shown  the  position  likely  to  result  from  neglect  of  this  abduction. 

is  applied,  so  that  the  extension  is  made  with  the  limb  in  this 
abducted  position  (see  Fig.  588). 

(c)  In  order  to  prevent  thigh  from  rotating  outward  below 
the  fracture  and  thus  carrying  the  leg  and  foot  with  it, — to  pre- 
vent, in  other  words,  eversion  of  the  foot, — a  bandage  six  inches 
wide  should  be  fastened  by  pins  below  the  calf  of  the  leg  to  the 


SUBTROCHANTERIC    FRACTURE 


427 


posterior  part  of  the  bandage  or  ham-splint,  and  brought  up  on 
the  outer  side  of  the  leg  and  fastened  to  the  long  outside  splint 
or  to  the  cradle  above.  The  leg  meanwhile  is  held  in  the  cor- 
rected position.  If  this  bandage  is  fastened  to  the  cradle,  the 
latter  should  be  fastened  firmly  to  the  bed. 


Fig.  589. — Action  of  the  muscular  pull  of  the  iliopsoas  and  of  the  external  rotators  in  producing  de- 
formity in  fracture  of  the  femur  high  up.     Upper  fragment  is  flexed  and  abducted  upon  the  trunk. 


(d)  The  sagging  backward  of  the  thigh  (see  Fig.  587)  is  pre- 
vented by  the  posterior  coaptation  splint  and  its  proper  padding. 
(vSee  Supracondyloid  hVacture  of  the  Femur.) 

Subtrochanteric  Fracture  of  the  Shaft  of  the  Femur. — 
h'ractures  of  the  upper  third  of  the  shaft  are  comparatively 
rare.     The  diagnosis  of  this  fracture  is  not  ordinarily  difficult. 


428 


FRACTURES   OF   THE   FEMUR 


The  displacement  is  characteristic :  The  upper  fragment  is  flexed 
and  abducted,  and  the  lower  fragment  overrides  the  upper  one 
and  is  shghtly  adducted.  The  treatment  should  restore  the 
line  of  the  thigh.  At  times  the  ordinary  extension  and  counter- 
extension,  as  for  a  fracture  of  the  middle  of  the  femur,  may 
prove  effective.  If  it  is  not  effective, — and  it  usually  is  not 
effective, — the  leg  and  lower  fragment  should  be  elevated  upon  an 
incHned  plane,  so  as  to  bring  the  lower  fragment  up  to  the  upper 
one,  for  it  will  be  found  impossible  to  lower  the  upper  fragment. 
Traction  should  then  be  made  in  the  line  of  the  elevated  thigh 
from  above  the  condyles  of  the  femur.     If  position  and  traction 


Fig.  590. — Case:  Oblique  subtrochanteric  fracture  of  shaft  of  femur  (X-ray  tracing). 


are  inefficient, — and  they  usually  are  ineffective, — then  sutuiing  of 
the  fragments  should  be  contemplated. 

Operative  Treatment. — It  will  be  found  impossible  to  correct  com- 
pletely the  ordinary  deformity  of  abduction  and  flexion  of  the  upper 
fragment  and  adduction  and  riding  up  of  the  lower  fragment  by 
traction  upon  the  lower  fragment,  no  matter  in  what  position  the 


SUPRACONDYLOID   FRACTURE 


429 


lower  fragment  may  be  placed  for  traction.  Traction  will  not  con- 
trol the  position  of  the  two  fragments  appreciably.  Rendering  the 
closed  fracture  open  by  incision  and  suturing  the  bones  in  position  is 
the  only  possible  way  of  securing  a  perfect  result,  either  anatomic- 
ally or  functionally.  The  surgeon  must  be  judicious  in  the  selec- 
tion of  the  patients  upon  whom  he  operates.  Even  though  old,  if 
the  patient  is  in  excellent  general  health,  the  operation  may  be 
done  with  every  prospect  of  success. 


Fig.  59I0— Spiral  fracture  of  the  shaft  of  the  femur  high  up  (X-ray  tracing). 


Supracondyloid  Fracture  of  the  Femur.— The  deformity 
is  characteristic  and  fairly  typical  see  Fig.  593) ;  displacement 
of  both  fragments  backward  is  sometimes  seen  (see  Fig.  599). 
The  upper  end  of  the  lower  fragment  is  displaced  backward, 
chiefly  through  the  pull  upon  it  by  the  gastrocnemius  muscle. 

Treatment  of  this  fracture  in  the  straight  and  extended  position 
is  usually  unsatisfactory.  It  is  necessary  either  to  flex  the  leg  in 
order  to  relax  the  gastrocnemius  muscle  or  to  do  a  tenotomy  upon 
the  tendo  Achillis.  One  or  both  of  these  procedures  having 
been  carried  out,  the  thigh  and  leg  should  then  be  placed  upon  a 


430  FRACTURES    OF    THE    FEMUR 

double  inclined  plane.  Pressure  by  pads  may  be  exerted  upon 
the  upper  end  of  the  lower  fragment  in  order  to  lift  it  forward 
into  apposition  with  the  upper  fragment.  Slight  traction,  if 
possible,  should  be  maintained  upon  the  lower  fragment.  Re- 
peated examinations  with  the  fluoroscope  will  indicate  when 
reduction   is   completed. 


Fig.  502. — Fractured   femur,   base   of  neck  driven  into  tlie  sliaft.     Spiral   fracture  of  shaft 
just  below  this  (Warren  .Museum,  6529). 

If  it  is  impossible  by  position,  padding,  and  traction  to  secure 
good  alignment  in  fracture  of  the  shaft  of  the  femur  above  the 
condyles,  it  is  best  to  correct  the  displacement  by  aid  of  an  incision. 
If  the  corrected  position  cannot  be  maintained  satisfactorily  the 
fragments  should  be  held  securely  by  plate  and  screws  or  by  one  or 
more  staples. 

Huntington's  method  of  traction  and  countertraction,  illustrated 
in  Fig.  594,  is  helpful  and  almost  necessary  to  satisfactory  main- 


SUPRACONDYLOID    FRACTURE 


431 


tenance  of  bony  apposition  while  fixative  apparatus  (plates, 
staples)  is  being  put  in  place  (see  Chapter  XVI).  Martin's  em- 
ployment of  direct  traction  on  the  distal  fragment  of  the  fractured 
femoral  shaft  is  to  be  recommended  in  fractures  with  overlapping 
of  fragments. 


Fig-  593- — Fracture  of  the  shaft  of  the  femur  along  the  condyles.  Showing  position  in  a  double 
inclined  plane  which,  together  with  padding,  assists  in  the  better  position  of  the  lower  fragment. 
Traction  not  illustrated  (Davison). 


Fig.  594. — Traction  apparatus  for  use  in  fracture  of  the  shaft  of  the  feraiir,  during  operation.     (After 

Huntington.) 

The  After-treatment  and  Prognosis  of  Fracture  of  the 
Thigh. — Inspection  of  the  fractured  limb  should  be  made  at 
least  daily.  Measurement  should  be  made  twice  a  week  during 
the  first  few  weeks,  the  internal  malleolus  being  rea,ched  through 
the  bandage.  Parts  of  the  apparatus  may  need  changing,  and 
straps  may  require  lightening  or  loosening.     The  heel  and  sacrum 


432 


FRACTURES   OF    THE    FEMUR 


will   require   attention   because   of   the   constant   pressure   from 
lying  in  one  position. 

Ordinarily,  there  will  be  little  or  no  pain  associated  with  the 
repair  of  the  fracture.  After  about  four  weeks  all  apparatus 
should  be  removed  and  the  hmb  thoroughly  inspected,  to  de- 
tect, if  possible,  any  uncorrected  deformity,  and  to  determine 
whether  union  is  yet  firm.  In  from  four  to  six  weeks  repair  in  a 
healthy  child  or  young  adult  should  have  advanced  to  the  stage 


F'g-  595- — Low  fracture  of  tlie  shaft  of   the  femur.     Displacement  of  the  lower  fragment  backward 
by  the  gastrocnemius  muscle,  and  of  the  upper  fragment  forward.     Overlapping  of  fragments. 


of  firm  union.  Ninety-seven  per  cent,  of  fractures  of  the  shaft  of 
the  femur  in  patients  under  ten  years  of  age  will  be  united  within 
seven  weeks  (Paul).  The  apparatus  should  then  be  reapplied. 
At  the  end  of  the  eighth  week  all  apparatus  should  be  finally  re- 
moved. The  thigh  should  be  washed  and  thoroughly  oiled. 
The  patient  should  be  permitted  to  lie  in  any  position  in  bed 
without  retentive  apparatus  for  one  week.  After  the  splints 
are  first  left  off  and  while  the  patient  is  still  in  bed  daily  systematic 
massage  to  the  whole  limb  should  be  practised,  together  with 
slight  passive  and  active  motion  at  the  knee-joint.  The  patient 
should  not  be  allowed  to  bear  weight  upon  the  unprotected  thigh 
until  after  the  ninth  week.     At  the  ninth  week  he  should  be 


SUPRACONDYLOID    FRACTURE 


433 


allowed  up  and  about  with  crutches,  and  a  moderately  high- 
soled  shoe  (two  inches)  should  be  worn  upon  the  foot  of  the  un- 
injured thigh.  He  should  bear  no  weight  upon  the  injured  leg. 
The  seat  of  the  fracture  should  be  protected  by  coaptation  splints 
and  straps  or  a  light  spica  plaster-of-Paris  bandage  from  the 
toes  to  above  the  waist.  At  the  end  of  twelve  weeks  all  support 
may  be  discarded,  and  the  adult  patient  encouraged  to  gradually 
bear  his  weight  upon  the  injured  limb.     Eighty-three  per  cent. 


Fig.  596.— Lateral  view.  Oblique  fracture  of  the  shaft  of  the  femur  low  down.  Little 
backward  displacement  of  lower  fragment.  Considerable  shortening  of  thigh  from  forward 
displacement  of  upper  fragment.     Man  aged  forty.     Recovery  (X-ray  tracing). 


of  all  fractures  of  the  shaft  of  the  femur,  including  those  in  adult 
life  and  childhood,  were  solidly  united  within  nine  weeks  (Paul). 
Of  course,  fractures  of  the  femur  vary  considerably  in  the  time  the 
patient  is  able  to  get  about,  but  the  foregoing  routine  is  that  of 
average  uncomplicated  cases. 

It  is  very  probable  that  massage  without  any  passive  motion, 

as  early  as  the  second  week,  to  the  region  of  the  knee  and  thigh 

will    prevent   much   of    the    knee-joint   disability   and    muscular 

atrophy  that  so  often  hinder  convalescence  in   these  cases.     It 

28 


434 


FRACTURES    OF    THE    FEMUR 


is  very  important  also,  in  order  to  gain  this  end,  to  see  that  the 
extension  is  made  from  around  and  above  the  condyles  of  the 
femur  and  not,  as  so  often  happens,  from  the  knee-joint  itself. 
It  ought  to  be  possible  to  avoid  all  knee-joint  stiffness  by  the 
judicious  use  of  massage  to  the  whole  limb  and  passive  motion 
to  the  knee-joint.  These  measures  in  many  cases  should  be 
instituted  and  practised  regularly  and  persistently  and  always 
cautiously  from  the  second  week  after  the  injury. 


I 


Fig.   59Vj — Same  as  figure  596.    Anteroposterior  view  (X-ray  tracing). 


The  ambulatory  treatment  of  fracture  of  the  thigh  by  means  of 
the  long  Taylor  hip  traction  splint,  a  high  sole  upon  the  shoe  worn 
on  the  well  foot,  and  crutches,  is  of  very  great  value,  especially 
in  children  and  young  adults.  The  hip-splint,  consisting  of  a 
long  outside  upright,  pelvic,  thigh,  and  calf  bands,  is  applied 
with  two  perineal  straps  (see  Figs.  60 1,  602).  The  traction  is 
made  through  the  windlass  at  the  foot-piece  after  fastening  the 
extension  strips  to  it.  The  countertraction  is  made  by  the  two 
perineal  straps.  The  thigh  is  securely  held  by  coaptation  splints 
and  a  bandage  about  the  thigh  and  splint.     The  patient  goes 


PROGNOSIS 


435 


about  with  crutches  and  a  high  sole  of  two  inches  upon  the  shoe 
worn  on  the  well  foot,  bearing  a  little  weight  upon  the  foot  of 
the  splint.  As  a  matter  of  fact,  the  real  value  of  this  method 
in  fracture  of  the  thigh  lies  in  the  improvement  to  the  general 
health  by  the  early  getting  into  the  upright  position  and  out 
of  bed.  This  application  of  the  ambulatory  method  certainly 
is  of  great  comfort  to  the  patient.     That  it  hastens  the  repara- 


Fig.  sqS — Oblique  fracture  of  the  shaft  just  above  the  knee,  with  splitting  apart  of  the  two 
condyles.  Extreme  displacement ;  necrosis  of  tip  of  upper  fragment.  Patient,  a  man  of  thirty- 
seven  years,  lived  for  five  months  (Warren  Museum,  specimen  1118). 


tive  process  is  yet  to  be  fully  demonstrated.  If  the  Taylor  hip- 
splint  is  used,  it  should  be  applied  when  union  is  found  to  be 
firm.  After  wearing  the  splint  in  bed  for  a  few  days  the  patient 
may  get  up  and  be  about. 

The  Prognosis. — What  shall  be  considered  a  satisfactory 
result  in  the  treatment  of  a  closed  fracture  of  the  shaft  of  the 
femur?     The  degree  of  restoration  of  function  can  not  be  deter- 


436  FRACTURES   OF   THE  FEMUR 

mined  with  accuracy  until  about  one  year  has  elapsed  after 
treatment  is  suspended.  The  following  six  requisites  for  a  satis- 
factory result  following  fracture  of  the  femur  are  those  reported 
by  a  committee  from  the  American  Surgical  Association,  and 
generally  accepted  as  forming  a  good  working  basis. 

For  a  result  to  rank  as  a  good  one,  it  must  be  estabhshed 
that  firm  bony  union  exists ;  that  the  long  axis  of  the  lower  frag- 
ment is  either  directly  continuous  with  that  of  the  upper  frag- 
ment or  is  on  nearly  parallel  lines,  thus  preventing  angular 
deformity;  that  the  anterior  surface  of  the  lower  fragment  main- 
tains nearly  its  normal  relation  to  the  plane  of  the  upper  frag- 
ment,   thus   preventing   undue   deviation   of   the   foot   from   its 


\ 
\ 
\ 

Upper  fragment  of  femur.- — "     'T  \  \  i 

I        r\     \       t 

Lower  fragment  of  femur. f"        "J         ^'^1  » 

/       /         /  / 


Patella 


-r\ 


Fig.  599 — Transverse  fracture  of  the  femur  in  the  lower  third  with  backward  displacement 
of  both  fragments.     Lateral  view  (X-ray  tracing). 

normal  position;  that  the  length  of  the  limb  is  exactly  equal  to 
its  fellow  or  that  the  amount  of  shortening  falls  within  the  limits 
found  to  exist  in  ninety  per  cent,  of  healthy  limbs — namely, 
from  one-eighth  to  one  inch ;  that  lameness,  if  present,  is  not  due 
to  more  than  one  inch  of  shortening ;  that  the  conditions  attending 
the  treatment  prevent  other  results  than  those  obtained. 

Results  After  Fracture  of  the  Thigh. — The  prognosis  as  to 
the  usefulness  of  the  thigh  after  fracture  deduced  from  the  sta- 
tistics available  is  of  Httle  value,  because  the  details  of  the  cases 
are  not  presented  nor  is  any  discrimination  made  between  the 
seats  of  fracture  and  the  ages  of  the  patients.  Realizing  these 
facts,  I  have  very  carefully  examined  and  classified  the  final 
results  several  years  after  treatment  had  ceased  in  thirty-five 


PROGNOSIS 


437 


cases  of  uncomplicated  fracture  of  the  shaft  of  the  femur  treated 
at  the  Massachusetts  General  Hospital.  The  treatment  in  all 
cases  was  practically  the  same:  a  Buck's  extension  with  outside 
T-splint,  or  a  long  Desault  apparatus,  and,  toward  the  end  of 
treatment,  a  plaster  spica  of  the  thigh,  groin,  and  trunk,  with 
crutches.  Even  though  this  number  of  cases  is  relatively  small, 
yet,  after  having  most  carefully  analyzed  them,  it  seems  highly 
probable  that  even  if  this  number  should  be  increased,  the 
ultimate  results  would  not  materially  differ.  These  thirty-five 
cases  have  been  arranged  in  three  groups,  according  to  age:  (a) 
Those  of  childhood;  (6)  those  of  adult  life;  and  (c)  those  of  old 
age.  (a)  Fourteen  cases  occurred  in  childhood,  the  ages  aver- 
aging seven  and  a  half  years.     Patients  were  heard  from  or  re- 


Upper  fragment. 


Fig.  6ooj. — Same  as  figure  599.    Anteroposterior  view,  showing  lateral  displacement. 


ported  for  examination  one  and  a  half  to  seven  years  after  the 
original  injury.  All  cases  were  treated  by  bed  extension,  coap- 
tation splints,  and  the  plaster  spica  to  thigh  and  hip.  All  have 
perfect  functional  results.  Four  cases  mention  slight  pain 
occasionally.  Three  of  these  four  cases  have  a  little  stiffness 
of  the  knee  upon  the  injured  side  one  and  a  half  years  after 
the  accident,  three  and  a  half,  and  three  years  respectively. 
(b)  Sixteen  cases  occurred  in  adults  whose  ages  ranged  from 
eighteen  to  forty-eight  years.  These  were  seen  or  reported  from 
one  to  six  years  after  the  original  injury.  Five  of  these  have 
unqualifiedly  perfect  results,  without  pain  or  stiffness.  The 
remaining  eleven  cases  have  limited  knee-joint  movements, 
aching  in  the  thigh,  pain  after  exercising,  pain  in  wet  weather, 
weakness    in    the    whole   leg,    and    slight    lameness   in    walking. 


438 


FRACTURES    OF    THE    FEMUR 


(c)  Five  cases  occurred  during  old  age.  The  patients  averaged 
fifty-eight  years.  These  were  seen  or  reported  from  two  to  six 
years  after  the  original  injury.  None  has  functionally  perfect 
results.  There  is  one  case  of  nonunion  of  the  thigh  with  shorten- 
ing of  the  limb.  Two  cases  must  use  a  cane  in  walking.  The 
knee  is  painful  and  motion  is  limited  in  all  cases.     Swelling  of 


Fig.  6oi. — Fracture  of  the  thigh.  Con- 
valescent ambulatory  splint  without  trac- 
tion. 


Fig.  602. — Fracture  of  the  thigh.  Con- 
valescent ambulatory  splint  without  trac- 
tion. Coaptation  splints  may  be  applied  to 
the  thigh  and  held  by  straps  enclosing  the 
thigh. 


the  leg  is  not  uncommon,  and  pain  in  wet  weather  is  very  com- 
monly complained  of  by  these  old  people. 

Considering  these  reported  cases  individually  and  grouped 
according  to  the  three  age  periods,  it  seems  reasonable  to  con- 
clude that  they  form  a  basis  for  a  fairly  accurate  judgment  as 
to  the  probable  outcome  of  these  injuries  to  the  shaft  of  the 
femur.     As  the  age  increases  the  liability  to  impairment  of  the 


fracture;  of  femur  in  the  newborn 


439 


function  of  the  limb  increases.     This  HabiHty  is  very  great  after 
fifty  years  are  passed. 

It  is  not  very  uncommon,  even  in  closed  fractures  of  the  femur, 
to  find  gangrene  of  the  leg  developing  because  of  laceration  or 
pressure  upon  the  great  vessels  of  the  limb.  Early  amputation 
of  the  thigh  just  above  the  fracture  will  be  necessary  in  these 
cases.     It  should  be  done  early  in  order  to  save  life.     In  the  aged 


Fig.  603. — Fracture  of  the  left  thigh  at  the  middle.    Union  solid.     Convalescence  hastened  by 
use  of  hip  splint  with  fixation  of  thigh  by  coaptation  splints  and  straps. 


the  shock  of  the  accident  may  prove  fatal.  In  open  fractures 
the  violence,  usually  direct,  has  been  so  great  that  the  soft  parts 
about  the  knee  and  throughout  the  whole  thigh  have  been  greatly 
torn  and  lacerated  on  either  side  of  the  fractured  bone.  The  shock 
in  these  cases  is  severe.     Recovery  is  always  doubtful. 

Treatment  of  Fracture  of  the  Femur  in  the  Newborn. — 
The  ordinary  method  of  treating  fracture  of  the  femur  has  disad- 
vantages and  is  impracticable  in  the  newborn  child. 


440  FRACTURES    OF    THE    FEMUR 

A  simple  method  is  the  placing  of  the  leg  in  a  flexed  position 
upon  the  body  similar  to  the  fetal  position.  The  front  of  the 
thigh  rests  upon  the  front  of  the  abdomen,  the  foot  will  reach  to 
the  shoulder.     The  trunk  is  carefully  protected  by  powder  and  a 


Fig.  604. — Fracture  of  the  femoral  shaft  in  the  newborn.  Xote  the  lower  extremity  forcibly  and 
completely  flexed  upon  the  body  !! thigh  extended),  foot  resting  in  cla\'icle,  bandage  holding  part  still. 
Comfortable  and  natural  position  for  newborn  baby. 

folded  soft  towel,  so  that  there  will  be  no  chafing  between  the 
thigh  or  leg  and  body.  The  position  of  the  lower  extremity  is 
maintained  by  a  swathe  carefully  adjusted  or  by  turns  of  a  band- 
age. 

This  hyperextended  position  is  borne  by  the  child  well,  and 
does  not  interfere  with  the  care  of  the  child.  This  position  should 
be  maintained  for  about  three  weeks.  Each  day  the  swathe  is 
removed,  the  position  being  maintained  while  the  parts  are 
powdered,  the  towel  readjusted,  and  the  leg  massaged.  Good 
results  follow  this  simple  method  (see  Fig.  604). 

Fracture  of  the  Thigh  in  Childhood. — This  is  usually  caused 
by  direct  violence.  The  fracture  is  often  incomplete.  The 
symptoms  are  those  of  the  same  fracture  in  the  adult.  The 
effusion  into  the  knee-joint  is  seen  perhaps  more  uniformly  than 
in  the  adult.  This  effusion  disappears  from  the  child's  knee-joint 
more  quickly  than  from  the  adult  knee-joint. 

Treatment. — After  reducing  the  fracture, — making  the  in- 
complete fracture  complete  if  perfect  reduction  can  not  be  ac- 
complished in  any  other  way, — the  problem  of  maintaining 
the  reduction  arises. 

In  children  of  ten  years  and  older  it  is  possible  to  use  the 
Buck's  extension.  A  plaster-of-Paris  spica  splint  from  the  calf 
of  the  leg  to  the  axilla  is  also  a  possible  method  of  immobilization. 

The  plaster-of-Paris  spica  is  most  efficient  in  fractures  seen 
immediately  after  the  trauma  and  in  those  in  which  little  or  no 
swelling  has  occurred  and  unattended  by  great  displacement. 
After  the  plaster  splint  has  been  applied  for  ten  days  it  should 


FRACTURE    OF    THE    THIGH    IN    CHILDHOOD 


441 


be  removed,  the  limb  thoroughly  examined,  and  a  new  plaster 
splint  applied  after  correcting  any  existing  deformities. 

In  children  under  ten  years  of  age  the  Cabot  posterior  wire 
frame  with  coaptation  splints  and  extension  is  a  good  method  of 
conveniently  and  efficiently  treating  a  fractured  thigh  or  frac- 
tured hip. 

The  Cabot  Posterior  Wire  Splint  (see  Fig.  605) :  The  splint  con- 
sists of  two  portions — a  body  part  and  a  leg  part.     The  patient 
lies  upon  the  body  part  with  the  thigh  and  leg  resting  upon  the 
leg  part,  as  upon  a  coaptation  splint.    Having 
a  vise  and  simple  iron  wire  the  size  of  an  ordi- 

'■  AD 

nary  lead-pencil,  this  splint  can  be  made  in  a 
few  moments ;  the  bending  of  the  wire  accord- 
ing to  the  diagram  and  fastening  the  free  ends 
by  a  strip  of  small -sized  wire  being  all  that  are 
required.  It  is  necessary  to  make  the  follow- 
ing measurements  before  bending  the  wire  to 
the  general  shape  shown  in  the  diagram — ■ 
namely,  D  E,  the  distance  from  the  axilla  to 
the  calf  of  the  leg;  A  D,  the  width  of  the  trunk; 
A  B,  from  the  axilla  to  a  point  midway  between 
the  crest  of  the  ilium  and  the  top  of  the  great 
trochanter;  F  H,  the  width  of  the  leg,  usually 
from  two  to  two  and  a  half  inches.  A  D 
and  B  C  are  bent  to  the  curve  of  the  back. 
B  C  is  so  bent  that  it  jumps  over  the  sacrum 
and  does  not  touch  posteriorly  excepting  at 
B  and  C.  The  long  rods  are  so  bent  as  to  adapt  them  to  the 
posterior  curves  of  the  buttock,  thigh,  popliteal  space,  and  leg 
(see  Fig.  606).  The  splint  is  covered,  as  in  the  posterior  wire 
splint  for  the  leg,  by  layers  of  sheet  wadding  and  cotton  ban- 
dages. A  swathe  is  attached  to  the  two  sides  A  B  and  D  H  of  the 
body  part  (see  Figs.  605,  and  607).  The  child  is  carefuUy  laid 
upon  this  splint,  the  body  swathes  adjusted,  the  extension  strips 
applied,  traction  made  by  weight  and  pulley  with  the  foot  of  the 
bed  elevated,  coaptation  splints  applied  and  held  in  position 
by  straps  that  include  the  posterior  wire  splint.  If  it  is  necessary 
to  move  the  child  for  the  making  of  the  bed,  for  the  use  of  the 
bed-pan,  or  for  bathing,  the  extension  may  be  unfastened  tern- 


Cl 

. 

F      E 
Fig.  605. — C  a  b  o  t 
wire  splint  for  fracture 
of  the  hip  atid  thigh. 


442  FRACTURES    OF   THE    FEMUR 

porarily  without  any  injury  to  the  fracture,  particularly  if  the 
coaptation  splints  are  then  temporarily  tightened  to  secure  a 
firmer  hold  on  the  thigh.  The  child  should  be,  of  course,  clean 
from  both  urine  and  feces,  and  the  fracture  immobilized. 

After  four  weeks  of  bed- treatment  the  child  may  be  up,  with 


Fig.  606. — The   Cabot  wire   splint   ready  for   use.     Lateral   view,  showing  curves   of  splint 
corresponding  to  small  of  back,  buttock,  and  knee. 


Fig.  607. — ^The  Cabot  wire  splint  ready  for  use.     Front  view,  showing  covering  of  Canton 
flannel  and  Canton-flannel  double  swathe  for  fixation  to  chest. 

crutches  and  a  high  shoe  with  the  Cabot  splint  applied.  Shoulder- 
straps  should  be  attached  to  the  splint  when  it  is  worn  in  the 
erect  position.  This  is  one  of  the  simplest,  cleanest,  and  most 
efficient  methods  of  treating  fracture  of  the  thigh  in  young  chil- 


Fig.  608. — Method  of  suspending  lower  limb  in  fracture  of  the  thigh  in  a  child.  Note  extension 
strips  held  by  a  bandage  from  groin  to  ankle,  spreader,  cord,  pulleys,  weight  and  post  for  holding 
pulley  (Davison).     See  Fig.  6og.  for  complete  dressing. 


FiK-  6of).— Fracture  of  the  femur  in  a  child.  Note  Bradford  frame  on  which  child  rests, 
the  position  of  the  lower  extremity.  Shoulders  and  trunk  of  child  held  fixed  by  straps  and 
swathe.  Note  coaptation  splints,  extension,  weight,  and  pulley.  A  comfortable  position  for 
child.     An  efricicrit  method  of  treatment. 


443 


444 


FRACTURES    OF    THE    FEMUR 


dren.  The  child  can  be  moved  with  freedom  and  without  pain. 
A  Hght  plaster-of- Paris  spica  bandage  may  be  used  in  conva- 
lescence with  crutches  and  a  high  shoe  on  the  uninjured  side. 
In  very  small  children  it  is  sometimes  wise  to  use  the  Brad- 
ford (see  Fig.  6io)  frame  and  vertical  suspension  (see  Fig.  609) 
of  one  or  both  thighs.  This  is  an  efficient,  comfortable,  and 
clean  method  of  treatment.  The  Bradford  frame  is  an  iron, 
frame-like  stretcher,  on  which  the  child  lies  and  to  which  the 
shoulders  and  hips  are  fastened  to  prevent  the  child's  moving 
about.  Counterextension  is  then  secured  by  the  immobiliza- 
tion  of  the  pelvis   and  hip.     The   extension   is  applied   to   the 


Fig.  610.— Bradford  bed-frame  for  fixation  of  trunk  in  fracture  of  the  thigh. 


thigh  and  leg  as  usual.  The  limb  is  flexed  on  the  body  to  a 
right  angle,  coaptation  splints  being  applied  to  the  thigh.  After 
the  novelty  of  the  position  passes  away,  the  child  is  perfectly 
contented.  As  soon  as  union  is  firm,  the  permanent  plaster 
spica  dressing  may  be  applied,  and  the  patient  may  be  up  and 
about  with  high  shoe  upon  the  well  foot  and  with  crutches.  The 
use  of  the  long  hip-splint  will  be  of  great  service  in  these  cases 
either  with  or  without  the  extension  foot-piece  (see  Figs.  601, 
602).  After  fracture  of  the  shaft  of  the  femur  in  children  there 
should  be  no  shortening  and  no  special  difficulty  in  convalescence. 
It  is  wise  to  guard  the  thigh  a  sufficient  time  after  union  is  firm 
to  insure  absolute  solidity  and  freedom  from  bowing  in  any 
direction  (see  Fig.  612). 

The  Making  of  the  Bradford  Frame. — It  is  most  easily  made 
from  |-  to  |-inch  gas  piping.  It  should  be  one  inch  wider  than 
the  width  of  the  hips,  and  six  inches  longer  than  the  height  of 
the  child.  It  should  be  covered  with  canvas,  so  as  to  leave  a 
space  under  the  buttocks  for  the  use  of  the  bed-pan. 


SBPARATION    OF   THE)    I.OWER    EPIPHYSIS 


445 


SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  FEMUR 
Anatomy. — The  lower  epiphysis  of  the  femur  is  the  largest 
of  the  epiphyses.  It  unites  with  the  shaft  of  the  bone  at  or 
about  the  twenty-first  year.  The  epiphysis  includes  the  whole 
of  the  articular  surface  of  the  lower  end  of  the  femur.  The 
points  of  origin  of  the  gastrocnemii  muscles  are  situated  upon 
the  epiphysis;  a  few  fibers  only  arise  from  the  diaphysis.  The 
inner  condylar  line  of  the  femur  is  continuous  with  the  inner 
lip  of  the  hnea  aspera,  and  terminates  at  the  adductor  tubercle, 
which  can  be  palpated  upon  the  inner  side  of  the  thigh  near  the 


Fig.  6ii. —  Fracture  of  the  thigh  in  a  child.  Vertical  suspension  as  in  figure  609  has  been 
followed.  After  two  weeks  the  lower  extremity  is  lowered  to  this  position  upon  an  inclined 
plane  before  completely  lowering  to  bed  level.  Inclined  plane  made  of  three  pieces  of  rather 
heavy  wood  for  solidity.  Note  the  extension  in  the  line  of  the  long  axis  of  the  lower 
extremity. 


knee-joint.  The  upper  and  outer  angle  of  the  trochlear  surface 
of  the  femur  can  be  palpated  best  with  the  knee  flexed.  A  line 
drawn  from  this  angle  of  the  trochlea  to  the  adductor  tubercle 
marks  the  level  of  the  lower  epiphysis  of  the  femur.  In  no 
position  of  the  knee-joint  are  the  bones  in  more  than  partial 
contact.  This  is  one  of  the  superficial  joints  of  the  body.  The 
strength  of  the  joint  lies  in  the  ligaments  and  fasciae  about  it. 
Unlike  the  elbow-  and  hip-joints,  it  does  not  depend  upon  the 
contour  of  the  bones  for  strength.  An  attempt  to  overextend 
and  to  bend  the  knee  laterally  brings  very  great  strain  to  bear 
upon  the  ligaments  that  are  attached  to  the  lower  femoral  epiph- 


446 


FRACTURES    OF   THE    FEMUR 


ysis.  If  this  strain  is  of  sufficient  force,  the  epiphyseal  cartilage 
gives  way,  and  the  epiphysis  separates  from  the  shaft  of  the 
femur.  The  common  cause  of  the  accident  is  the  catching  of 
the  leg  or  thigh  in  the  spokes  of  a  revolving  wheel.  The  accident 
most  often  occurs  to  boys  about  ten  years  old  (see  Figs.  613, 
614)- 

The  epiphysis  usually  separates  without  splintering  the  diaph- 
ysis.     The  periosteum  is   stripped   for  a  considerable   distance. 


Fig.  612. — Old  fracture  of  the  thigh  witli  deformity.     Due  to  use  of  unprotected  thigh  before 
complete  consolidation  of  fracture  (Warren). 


About  half  the  cases  are  open,  the  end  of  the  diaphysis  projecting 
through  the  skin  of  the  popliteal  space.  The  knee-joint  is  usually 
unopened.  There  may  be  almost  no  displacement  of  the  frag- 
ments. A  lateral  sliding  of  the  epiphysis  has  often  been  observed. 
One  condyle  has  been  found  in  the  popliteal  space,  but  com- 
monly the  epiphysis  lies  in  front  of  the  shaft  of  the  femur  with 
its  separated  surface  in  contact  with  the  shaft  (see  Figs.  615, 
616,  617).  The  diaphysis  is  displaced  backward  and  down- 
ward into  the  popliteal  space,  because  the  high  attachment  of 


SEPARATION    OF   THE    LOWER    EPIPHYSIS  447 

the  gastrocnemii  has  not  been  stripped  off  the  shaft.  The  frac- 
turing force  is  the  most  important  factor  in  determining  the  dis- 
placement of  the  lower  end  of  the  upper  fragment.  The  nerves 
of  this  region  may  be  pressed  upon  or  lacerated,  and  this  may 
be  the  cause  of  great  pain  attending  the  accident.  The  popliteal 
vessels  may  be  compressed,  stretched,  or  even  ruptured.  Con- 
sequently, interference  with  the  circulation  may  result.  This 
may     be    moderate    and     temporary,     or    extreme,    and    result 


Fig.  613.— Case:  Boy,  el(;\tn  years  of  age.  Separation  of  the  lower  femoral  epiphysis. 
Photograph  taken  four  hours  after  the  injury.  Note  inversion  of  the  limb  ;  fullness  of  lower 
third  of  thigh  posteriorly;  fullness  over  head  of  tibia  ;  fullness  in  popliteal  space  (X-ray 
tracing,  Fig.  615.  explains  the  evident  deformity). 


Fig.  614. — Case  same  as  figure  613.    Separation  of  the  lower  femoral  epiphysis  of  the  left  leg. 
Contrast  two  knees  (see  X-ray  tracing,  Fig.  615). 


in  gangrene  of  the  leg.  The  shock  attending  this  accident  is 
often  great.  Suppuration  may  appear  in  closed  separations, 
although  it  is  infrequent;  it  is  much  more  likely  to  appear  in 
open  lesions.  Sloughing  of  the  skin  is  not  unusual  from  the  bony 
pressure.  Gangrene  of  the  leg  sometimes  occurs.  Necrosis 
of  bone  is  not  unlikely  to  result,  particularly  if  the  separation 
of  the  periosteum  is  great  (see  Fig.  618). 

Diagnosis. — After  severe  trauma  to  the  region  of  the  knee 


448 


FRACTURES    OF   THE    FEMUR 


there  are  three  injuries  that  should  be  considered  possible:  a 
dislocation  of  the  knee-joint,  a  supracondyloid  fracture  of  the 
femur,  or  a  separation  of  the  lower  epiphysis  of  the  femur. 

There  may  be  so  much  swelling  that  a  satisfactory  examination 
is  impossible.  Ordinarily,  careful  palpation  will  detect  the  bony 
outlines  of  a  dislocation.  This  is  extremely  rare  in  children. 
The  crepitus  of  a  supracondyloid  fracture  is  bony  and  hard,  and 
the  displacement  of  the  distal  fragment  into  the  popliteal  space 
evident.     All  fractures  at  the  knee  are  not  necessarily  supra- 


Diaphysis  of  femur.  -  — \  — 


\ Lower  femoral 

epiphysis. 

—  Patella. 


^^ 7 Condyle  of  femur. 


— >■  ■  Upper  epiphysis 
of  tibia. 


Diaphysis  of  tibia. 

Fibula. 


Fig.  615. — Lateral  view.  Case  of  figure  613.  Boy,  aged  eleven  years.  Separation  of  the 
lower  femoral  epiphysis.  Displacement  forward  of  epiphysis  and  backward  of  lower  end  of 
shaft  (see  Figs.  613,  614.  X-ray  tracing). 


condyloid.  Several  cases  of  fracture  of  one  condyle  of  the  femur 
into  the  joint  are  reported.  The  separated  epiphysis  itself 
may  be  split  through  into  the  joint.  A  severe  trauma  to  the 
knee,  a  cart-wheel  accident  to  a  young  boy,  attended  by  con- 
siderable shock,  followed  by  great  swelling  of  the  knee,  a  fullness 
in  the  popliteal  space,  feeble  or  absent  pulsation  in  the  dorsalis 
pedis  and  posterior  tibial  arteries,  increased  lateral  and  antero- 
posterior mobility  at  the  knee,  and  soft  crepitus  form  the  picture 
characteristic  of  a  separation  of  the  lower  femoral  epiphysis. 
Prognosis. — It  is  impossible  to  state  positively  that  in  any 


SEPARATION    OF   THE    LOWER    EPIPHYSIS 


449 


given  case  there  will  or  will  not  be  shortening  of  the  leg  upon 
the  injured  side  because  of  a  cessation  of  growth  in  the  femoral 
epiphysis.     If  the  epiphysis  is  separated  without  great  lacera- 


Epiphyseal  line. 
Lower  femoral  epiphysis. 


Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


Fig.   6i6. — Same  case  as  figure  615.  Anteroposterior  view  of  uninjured  knee  in  a  child  eleven 
years  of  age,  showing  epiphysis  in  position  (X-ray  tracing). 


j-  — / Lower  femoral  epiphysis. 


Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


Fig.  f>j7. — Same  case  as  figure  615.    Anteroposterior  view  of  displaced  lower  femoral  epiphysis 
in  a  boy  eleven  years  old. 


tion  and  periosteal  denudation  and  is  replaced  soon  after  the 

injury,  the  chances  are  that  there  will  be  a  minimum  amount 

of  shortening  of  the  affected  leg.     There  is  recorded  one  case  of  a 
29 


450 


FRACTURES    OF   THE    FEMUR 


boy  seven  years  old,  separation  of  lower  femoral  epiphysis,  re- 
placed eight  weeks  later  by  incision,  whose  legs  two  years  after- 
ward had  grown  and  were  of  exactly  the  same  length.  This 
case  demonstrates  that  separation  of  this  epiphysis,  even  after 
reduction  eight  weeks  subsequently,  does  not  interfere  with  the 
growth  of  the  bone.  After  open  incision  and  replacing  of  the 
epiphysis  in  closed  fractures  good  results  are  to  be  expected  as 
far  as  the  usefulness  of  the  joint  is  concerned.  Slight  necrosis 
of  bone  may  attend  convalescence.  If  the  separation  is  closed 
and  reduction  is  impossible  by  manipulation  alone,  open  incision 
should  be  made. 

Lower  femoral  epiphysis. 

y 


—  i Patella. 

'Mlill 


Diaphysis  of  femur. 


Upper  epiphysis  of 

tibia. 


Diaphysis  of  tibia. 


Fig.  6i8. — Separation  of  lower  epiphysis  of  the  femur  with  displacement  forward  and  upward 
between  femoral  diaphysis  and  patella  (Warren  Museum,  S116-1). 


Treatment. — If  the  vessels  are  torn ;  if  there  is  great  laceration 
of  the  soft  parts,  amputation  should  be  performed.  If  the  sepa- 
ration is  open  and  the  shaft  of  the  femur  protrudes  through  the 
wound,  and  much  of  the  diaphysis  is  seen  to  be  denuded  of  perios- 
teum, the  diaphysis  should  be  resected  to  the  limit  of  periosteal 
separation,  and  then  the  bone  reduced.  It  may  be  necessary  to 
enlarge  the  opening  in  the  soft  parts  before  it  is  possible  to  reduce 
the  bone.     If  the  separation  is  closed,  reduction  by  manipulation 


SEPARATION   OP  The   LOWER   EPIPHYSIS 


451 


should  be  attempted;  if  successful,  the  leg  should  be  flexed  to  a 
right  angle  or  an  acute  angle  and  immobilized  in  a  plaster-of- 
Paris  splint. 

The  pressure  downward  is  upon  the  edge  of  the  displaced 
epiphysis  at  the  point  indicated  by  the  line  pointing  to  the 
"  lower  femoral  epiphysis  "  in  the  figure. 

Reduction  by  Manipulation  When  the  Fragment  is  Displaced 
Forward. — While  an  assistant  makes  traction  upon  the  leg,  the 


Fig.  619. — Diagram  to  show  method  of  reduction  of  separated  femoral  epiphysis  by  incision. 
Retractors  are  upon  diaphysis  and  epiphysis,  and  lines  of  traction  are  shown  by  arrows. 


Fig.  620. — Cabot  splint  arranged  as  double  inclined  plane  for  epiphyseal  separation  at  the 
lower  end  of  femur.  B,  The  part  behind  the  knee-joint,  may  be  bent  to  a  more  acute  angle; 
C,  the  body  portion,  is  to  be  molded  to  the  trunk  ;  A,  the  foot-piece.  With  the  angle  at  £ 
obliterated,  the  splint  may  be  used  for  fracture  of  the  leg  in  childhood. 


surgeon,  grasping  the  thigh  above  the  condyles  with  the  fingers  in 
the  popliteal  space,  making  pressure  on  the  upper  fragment,  pushes 
with  his  two  thumbs  upon  the  upper  border  of  the  displaced 
epiphysis  (see  Fig.  616).  The  pressure  downward  is  upon  the 
edge  of  the  displaced  epiphysis  at  the  point  indicated  by  the  line 
pointing  to  the  "lower  femoral  epiphysis  "  in  the  figure.  The  leg  is 
gradually  flexed.  If  the  reduction  is  achieved,  a  soft  grating  sen- 
sation will  have  been  felt,  and  the  shortening  of  the  leg  that  ex- 


452  FRACTURES    OF   THE    FEMUR 

isted  previous  to  reduction  will  disappear.     The  contour  of  the 
knee  will  assume  a  somewhat  normal  appearance. 

The  Operative  Method  of  Reduction. — The  obstacle  to  reduction 
is  no  single  band  or  obstruction,  it  is  the  retraction  and  tension 
maintained  by  the  fasciae,  ligaments,  and  muscles  of  the  thigh 
upon  the  tibia.     This  retraction  is  so  great  that  the  tibia  is  held 


Fig.  621. — Separation  of  tlie  lower  femoral  epiphysis  in  a  boy  fourteen  years  old.  Reduc- 
tion without  operation.  Recovery.  This  X-ray  was  taken  after  recovery.  Before  operation 
the  X-ray  was  similar  to  that  shown  in  Frontispiece  "  C."  Functionally  slight  loss  of  exten- 
sion. 


crowded  against  the  lower  end  of  the  upper  fragment,  and  pre- 
vents the  replacing  of  the  epiphysis.  An  incision  is  best  made 
over  the  denuded  shaft  of  the  femur  on  the  outer  side  of  the  leg. 
The  shaft  and  the  epiphysis  are  exposed  in  the  wound.  Traction 
should  be  made  by  means  of  periosteal  retractors  upon  the  epiph- 
ysis, and  countertraction  upon  the  diaphysis  while  the  leg  is  slowly 


SEPARATION    OF   THE    LOWER   EPIPHYSIS 


453 


flexed  from  the  completely  extended  position,  as  indicated  in  the 
figure  (see  Fig.  618).  This  will  result  in  the  reduction  of  the  dis- 
placement. Suture  of  the  bones  may  be  needed  to  retain  the  re- 
placed epiphysis  in  position.  The  flexed  position  of  the  leg  will 
assist  materially  in  retaining  the  fragment  in  position.  The  ap- 
plication of  a  light-weight  plaster-of- Paris  circular  bandage  from 
the  toes  to  the  groin,  with  the  leg  flexed  to  a  right  angle,  will  im- 
mobilize the  parts. 

After-union  is  firm  between  the  epiphysis  and  shaft.  After 
three  or  four  weeks  the  leg  may  be  gradually  extended.  The  foot 
of  the  injured  leg  may  be  touched  to  the  floor  while  the  plaster 


Fig.  622.- — Case  :  Boy,  aged  eleven  years.  Separation  of  left  lower  femoral  epiphysis;  in- 
cision, reduction.  Recovery.  After  six  months,  useful  leg.  Knee  motion  in  flexion  beyond 
a  right  angle  as  shown  (see  frontispiece  and  Figs. 613-61S  inclusive). 


splint  is  in  place  about  five  weeks  after  the  injury.  Shght  weight 
may  be  borne  upon  it.  The  plaster  should  be  removed  after  about 
six  weeks,  and  gentle  active  and  passive  motion  made  at  the  knee- 
joint.  Massage  to  the  calf  of  the  leg  and  the  thigh  should  be  given 
daily.  A  flannel  bandage  applied  to  the  foot,  ankle,  leg,  and  thigh 
will  be  all  the  support  that  is  needed.  After  about  ten  weeks 
the  boy  should  be  allowed  to  step  on  the  foot  all  he  chooses.  At 
first  he  will  do  this  with  fear,  but  soon  with  confidence.  There 
will  usuallv  be  a  little  limitation  of  motion  in  the  knee-joint  (see 
Figs.  622,  623). 

Traumatic  Gangrene,  Septicemia,  Malignant  Edema. — Fractures 


454 


FRACTURES   OF    THE    FEMUR 


complicated  with  laceration  of  the  large  vessels  are  a  frequent 
cause  of  gangrene.  If  an  acute  infectious  process  starts  in  a  limb 
with  traumatic  gangrene,  the  gangrene  spreads  with  frightful 
rapidity.  The  general  disturbance  is  very  great.  A  septicemia 
of  grave  type  results.  To  such  cases  in  which  there  is  much  gas 
formation,  associated  with  edema,  and  which  results  in  rapid  de- 


Fig.  623. — Case  same  as  that  in  figure  622.  Separation  of  lower  femoral  epiphysis.  Note 
degree  of  extension  possible  and  cicatrix  of  incision  six  months  after  operation.  Note  also 
absence  of  deformity. 

struction  of  tissue,  the  name  malignant  edema  is  given.  The 
specific  bacillus  of  malignant  edema  will  be  discovered  in  the 
blood  and  tissues  far  above  the  wound  of  the  soft  parts. 

The  proper  treatment  is  early  high  amputation  with  stimulation 
of  the  heart  by  strychnin  and  alcohol. 

Fat  Embolism. — Fat  embolism,  to  a  greater  or  less  degree, 


SEPARATION    OF   THE    LOWER   EPIPHYSIS  455 

exists  in  every  case  of  fracture.  Free  fat,  open  venous  channels, 
and  a  force  to  drive  the  fat  are  essential  to  the  production  of  fat 
embolism.  It  is  most  evidently  present  in  those  cases  associated 
with  great  laceration  of  tissue  and  in  open  fractures.  The  soft  fat 
of  the  medullary  tissue  is  the  source  of  the  fat-drops  that,  getting 
into  the  venous  circulation,  are  carried  directly  to  the  pulmonary 
capillaries,  where  they  lodge  unless  the  blood  pressure  is  sufficient 
to  force  them  out  of  the  lung  capillaries  on  into  the  systemic 
circulation.  They  then  lodge  in  the  brain,  kidneys,  or  other 
organs.  The  oil  is  removed  from  the  circulation  by  oxidation 
and  saponification,  by  a  phagocytic  action  of  the  leukocytes  and 
directly  by  the  liver  and  kidney.  The  danger  in  fat  embolism  is 
twofold :  that  the  patient  may  die  from  asphyxiation,  due  to  the 
imperfect  oxygenation  of  the  blood  because  of  the  rapid  occlusion 
of  the  pulmonary  capillaries  with  fat  globules  and  that  he  may 
die  from  cerebral  complications. 

Symptoms. — There  are,  therefore,  two  varieties  of  cases  clini- 
cally, the  pulmonary  and  the  cerebral,  according  as  lung  or  brain 
complications  predominate. 

The  pulmonary  type  will  present  rapid  respiration,  dyspnea, 
pallor  and  then  cyanosis,  followed  by  a  weak  circulation  and  the 
signs  of  pulmonary  edema,  the  expectoration  of  a  bloody,  frothy 
mucus,  along  with  the  physical  signs  of  edema  of  the  lungs. 

The  cerebral  type  presents  fewer  pulmonary  signs  but  chiefly 
delirium,  restlessness,  stupor,  and  finally  coma  and  possibly 
convulsions.  There  are  rarely  signs  of  any  focal  disturbance 
in  the  brain.  The  urine  should  be  examined  for  fat  and  albumin. 
The  eye  ground  should  be  examined  to  detect  hemorrhages  and 
the  changes  of  choked  disc. 

Diagnosis. — Shock,  acute  pulmonary  lesions  from  other  causes 
than  fat  embolism,  acute  urinary  suppression,  ordinary  embolism, 
and  traumatic  hemorrhage  all  should  be  distinguished  from  fat 
embolism.  Keeping  in  mind  the  two  pictures  of  fat  embolism 
and  their  salient  characteristics  it  will  be  difficult  to  confound 
these  other  lesions  with  it. 

Treatment. — Stimulation  of  the  heart  for  its  extra  work  is  in- 
dicated. Immobilization  of  the  fractured  part  to  prevent  more 
fat  from  getting  into  the  circulation  and  the  administration  of 
oxygen  to  relieve  asphyxia  are  important  in  the  treatment. 


CHAPTER  XIIT 

FRACTURES  OF  THE  PATELLA 

Anatomy. — A  knowledge  of  the  anatomical  relations  of  the 
patella  is  necessary  to  a  perfect  understanding  of  the  fractures  to 
which  it  is  liable  (see  Figs.  624-626).  Attached  to  the  patella 
upon  its  upper  border  is  the  tendon  of  the  quadriceps  extensor 
muscle.  Upon  each  side  of  the  bone  are  attached  the  vastus  in- 
ternus  and  vastus  externus  respectively.  Below  the  insertions  of 
the  vasti  is  a  portion  of  the  low  attachment  of  the  fascia  lata  of 


Fig.  624. — Anterior  view  of  normal  patella. 

the  thigh.  At  the  lower  border  of  the  patella  is  the  patellar  ten- 
don. This  tendon  is  inserted  into  the  tubercle  of  the  tibia,  and 
it  is  separated  from  the  head  of  the  tibia  by  a  bursa  and  a  pad  of 
fat  tissue.  The  tendon  of  the  quadriceps,  the  insertions  of  the 
vasti  muscles,  and  the  patellar  tendon  are  all  continuous  with  the 
strong  fascia  lata  surrounding  the  thigh.  The  fascia  lata  is  at- 
tached below  to  the  condyles  of  the  femur,  the  sides  of  the  patella, 
the  tuberosities  of  the  tibia,  the  head  of  the  fibula,  and  to  the  deep 
fascia  of  the  leg  in  the  popliteal  space.     The  patella  is  seen,  there- 

456 


ANATOMY 


457 


fore,  to  lie  in  a  strong  fibrous  sheath  that  encircles  the  knee  and 
is  attached  to  various  bony  prominences.  The  synovial  mem- 
brane of  the  knee-joint  lies  directly  beneath  and  attached  to  the 
posterior  surface  of  the  patella.  Laterally  and  posteriorly  the 
synovial  membrane  lies  next  to  the  encircling  fascia  of  the  joint. 
The  deep  bursa  of  the  femur  lies  in  front  of  the  lower  end  of  the 
femur  beneath  the  quadriceps  muscles,  and  often  communicates 
with  the  knee-joint.  The  tubercle  of  the  tibia  is  on  a  level  with 
the  head  of  the  fibula.  The  outline  and  anterior  surface  of  the 
patella  can  be  palpated  throughout.  When  the  leg  is  completely 
extended  and  is  at  rest,  the  patella  can  be  moved  from  side  to 


Fig.  625. — Posterior  view  of  normal  patella, 
showing  the  two  articular  surfaces  for  the  con- 
dyles of  the  femur.  Note  the  lower  tip  of  pa- 
tella is  extra-articular. 


Fig.  626. — Lateral  view  of  normal 
patella.  Note  lower  portion,  extra- 
articular. Fracture  in  this  lower  por- 
tion will  not  open  knee-joint. 


side.  The  numerous  longitudinal  striae  on  the  anterior  surface 
of  the  patella  can  be  detected.  In  these  the  tendinous  bundles  of 
insertion  of  the  rectus  are  embedded.  It  is  these  fibers  that  fold 
in  over  the  broken  patella  and  prevent  the  approximation  of  the 
fragments.  The  ligament  of  the  patella  is  parallel  with  the  axis 
of  the  leg. 

Fracture  of  the  patella  occurs  through  either  muscular  contrac- 
tion and  strain,  a  "tear  fracture,"  or  through  direct  violence,  a 
"blow  fracture."  The  form  of  the  fracture  is  not  altogether 
dependent  upon  the  causative  force.  The  "tear  fracture"  will 
be  transverse  and  clean  cut,  the  "blow  fracture"  comminuted  and 
irregular.     The  knee-joint  is  generally  opened,  i.  e.,  the  synovial 


458 


FRACTURES    OF   THE   PATELLA 


membrane  is  generally  torn.  The  synovial  membrane  is  reflected 
from  the  posterior  surface  of  the  patella,  some  distance  from  the 
most  inferior  tip  of  the  bone.     It  is  possible,  therefore,  for  a  frac- 


c 

3 

E 

H| 

v 

o 

^H 

m 

.C 

I 

m 

_rt 

1 

V 

2 

1 

01 

M 

^ 

M 

wM 

IHIH 

Fig.  627. — Skiagraph  of  normal  right  knee-joint  in  an  adult. 


ture  to  occur  at  the  lower  portion  of  the  bone  for  some  consider- 
able distance  from  the  lower  edge  without  opening  the  knee-joint. 
A  longitudinal  fracture  of  the  patella  may  occur.  Following 
injury  to  the  knee  it  should  not  be  overlooked.  A  persistent 
joint   effusion   or   recurring   joint   effusions   from   slight   injuries 


SYMPTOMS 


459 


or  overexertion  may  suggest  the  true  condition  to  be  a  longitudinal 
fracture  of  the  patella  and  not  primarily  a  chronic  arthritis. 

Symptoms. — There  are  pain  in  the  knee  and  immediate  disabil- 
ity, varying  from  partial  to  complete  loss  of  power  in  extension 
and  in  flexion.  Inability  to  extend  the  leg  is  suggestive  of  either 
a  fracture  of  the  patella,  a  rupture  of  the  patella  ligament,  a  rupture 
of  the  quadriceps  tendon,  or  it  may  be  associated  with  a  fracture 
of  the  beak-shaped  process  of  the  upper  part  of  the  tibia — the 
tibial  tubercle.  The  patient  may  be  unable  to  rise  or,  if  he  can 
stand,  he  can  not  move  except  backward,  and  then  only  by 
dragging  the  foot  of  the  injured  limb  upon  the  ground.  The 
patient  is  often  unable  to  raise  the  heel  from  the  bed  when  Iving 
upon  the  back.  Swelling  of  the  knee,  which  at  first  is  slight, 
after  three  or  four  hours  may  become  very  great  (see  Fig.  628). 
The  swelling  is  due  to  the  accumulation  of  blood  and  synovial 
fluid  in  the  knee-joint.  A  traumatic  synovitis  exists.  The  im- 
mediate swelling  of  the  knee  may  become  great  enough  to  demand 
an  incision  to  relieve  the  tension  upon  the  skin,  to  prevent  slough- 
ing of  the  skin  above  the  broken  patella.  Immediately  after  the 
accident  crepitus  may  be  elicited  by  pressing  the  two  fragments 


Fig.  628.— Case  :  Right  knee  normal  ;  left  knee,  fracture  of  patella.     Two  days  after  accident. 
Observe  swelling  of  whole  knee.    Joint  filled  with  fluid. 


together.  When  the  knee-joint  is  distended  by  fluid,  it  is  often 
impossible  even  to  detect  the  fragments  of  the  patella,  but  as  the 
fluid  subsides  and  the  sulcus  between  the  bones  is  felt,  crepitus 
can  again  be  detected.  The  degree  of  the  separation  of  the  frag- 
ments is  dependent  upon  the  amount  of  distention  of  the  joint 
and  uprm  the  extent  of  the  tearing  of  the  lateral  aponeurosis 


Fig.  6291 — Fracture  of  the  patella  ;  fi- 
brous union.  A  growth  of  bone  has  taken 
place  about  the  lower  fragment  (Warren 
Museum). 


Fig.  630. — Fracture  of  the  patella.  Note 
fracture  of  lower  fragment.  A  common 
form  of  fracture. 


Line  of  fracture. i 


Fig.  631. — Fracture  of  the  patella. 


Fig.  632. — Fracture  of  patella  ;  union 
with  long  fibrous  band.  Note  separation 
of  fragments  (Warren  Museum,  specimen 
5253)- 


Fig-  633.' — Ham-splint  without  strap, 
showing  proper  length  and  relation  to 
thigh  and  leg  posteriorly. 


460 


TREATMENT 


461 


(fascia  lata)  of  the  knee,  permitting  muscular  contraction  and 
retraction.  If  the  causative  violence  is  associated  with  a  wound 
of  the  soft  parts,  there  will  be  evident  a  contusion  or  an  abrasion 
of  the  skin  or  a  lacerated  wound  opening  the  knee-joint  making 
the  fracture  an  open  one. 

Treatment. — The  indications  to  be  met  are  the  limitation  and 
removal   of  the   effusion,  the   reduction   of   the   fragments,   the 


Fig.  634. — Improper  method  of  applying  a  ham-splint.     The  knee-joint  is  not  immobilized. 
Flexion  is  possible.     Straps  i  and  2  are  insufficient. 


Fig.  635. — Proper  method  of   applying  a  ham-splint.     The  third  adhesive-plaster  strap  (3) 
prevents  flexion  of  the  knee. 


maintenance  of  the  reduction  until  union  is  satisfactory,  and  the 
restoration  of  the  functions  of  the  joint  to  their  normal  condition. 
The  Limitation  and  Removal  of  the  Effusion. — If  the  fracture  is 
seen  before  there  is  great  swelling,  limitation  of  the  swelling  may 
be  effected  by  immobiUzation  of  the  knee  and  the  accurate  appli- 
cation of  an  elastic  rubber  bandage.  If  the  bandage  is  not  at 
hand,  sponge  compresses  may  be  used — viz.,  two  slightly  moist- 
ened bath  or  carriage  sponges  are  allowed  to  dry  under  pressure 


462 


FRACTURES    OF   THE    PATELLA 


sufficient  to  flatten  them.  These  are  placed  upon  each  side  of  the 
knee  and  over  it,  and  are  held  by  a  few  turns  of  a  roller  bandage. 
Cool  water  is  then  poured  over  the  whole.  As  the  sponges  absorb 
the  water  they  enlarge,  causing  equable  and  firm  pressure  on  the 
knee,  thus  very  materially  hindering  the  accumulation  of  fluid 
and  favoring  its  absorption.     These  wet  sponge  compresses  should 


Fig.  636. — Expectant  method  of  treating  fracture  of  the  patella.  Leg  extended  on  pos- 
terior wire  splint.  Fragments  held  by  two  straps.  Fluid  has  left  the'joint.  y4,  Side  splints  ; 
B,  coaptation  splints  reflected. 


Fig.  637  — Expectant  method  of  treating  fracture  of  the  patella.     Same  as  figure  636,  with  the 
addition  of  coaptation  splints  to  the  thigh,  padding,  and  straps. 


be  left  in  position  for  from  twelve  to  twenty-four  hours,  and  then 
a  fresh  set  used. 

Massage  skilfully  applied  to  the  whole  limb,  irrespective  of  the 
method  of  treatment  eventually  instituted,  will  not  only  assist  in 


EXPECTANT   TREATMENT  463 

the  absorption  of  the  fluid,  but  will  preserve  intact  the  muscles  of 
the  limb.  Massage  to  be  effective  should  be  applied  at  least  twice 
daily,  and  from  fifteen  minutes  to  half  an  hour  at  a  time.  Slight 
pain  will  be  felt,  but  after  a  time  massage  will  be  painless  and 
give  great  comfort. 

Ihe  Reduction  of  the  Fragments. — No  attempt  should  be  made 
to  reduce  the  fragments  until  nearly  all  the  fluid  is  removed  from 
the  knee-joint.  Reduction  is  accomplished  by  immobilization 
of  the  knee-joint,  by  fixation  of  the  lower  fragment,  and  by  trac- 
tion upon  and  fixation  of  the  upper  fragment.  The  leg  should  be 
extended  completely  and  the  knee  immobilized  either  upon  ham- 
splint  (see  Figs.  633,  634,  635)  or  upon  a  Cabot  posterior  wire 
splint.  The  ham-splint  is  preferably  made  from  a  plaster-of- 
Paris  bandage.  The  fragment  is  held  fixed  by  a  strap,  pref- 
erably of  adhesive  plaster,  placed  obliquely  about  the  leg  and 


Fig.  638. — Expectant  method  of  treating  fracture  of  the  patella.  Same  as  figure  637  with 
the  addition  of  two  lateral  splints,  padding,  and  straps.  A  posterior  wooden  splint,  seen 
better  in  figure  637.  and  elevation  of  the  limb. 

splint,  and  fastened  to  the  sphnt  above  the  fragment  (see  Figs. 
'5,36,  637,  638,  639).  The  upper  fragment  is  drawn  down  first  by 
elevation  of  the  leg  upon  an  inclined  plane,  which  relaxes  the 
quadriceps  extensor  muscle,  then  by  traction  obtained  by  a  strap 
passed  obliquely  above  the  upper  fragment  and  fastened  to  the 
splint  below  the  fragment.  The  upper  strap  will  need  repeated 
adjustment  as  the  plaster  slips  and  as  the  fluid  disappears  from 


464 


FRACTURES    OF    THE    PATELLA 


the  joint.  To  facilitate  traction  by  this  upper  strap,  the  quad- 
riceps muscle  should  be  held  firmly  by  coaptation  splints  and 
straps  encircling  the  posterior  splint.  The  quadriceps  can  not 
then  actively  pull  upon  the  upper  fragment.  The  tendency  of 
these  two  straps  thus  applied  will  be  to  tilt  the  broken  surfaces 
of  the  two  fragments  upward  and  apart,  particularly  if  there  is 
fluid  in  the  joint.  It  is  important,  therefore,  to  place  a  third 
strap  over  the  two  broken  edges  of  the  fragments,  in  order  to  hold 
them  down  to  their  proper  level  and  to  assist  in  bringing  them  into 


Fig.  639. — Expectant  method 
of  treating  fracture  of  tlie  patella. 
Anterior  view  of  apparatus  com- 
plete. The  padding  of  the  side 
splints  is  shown. 


Fig.  640. — Extent  of  flannel  bandage  to  knee, 
applied  after  all  immobilizing  apparatus  is  re- 
moved.   The  bandage  is  started  at  i. 


apposition.  The  coaptation  splints  should  be  removed  at  every 
massage  treatment,  the  upper  fragment  being  steadied  by  an 
assistant.     The  straps  about  the  patella  need  not  be  removed 


EXPECTANT   TREATMENT 


465 


during  the  massage.  They  will  be  of  no  inconvenience.  As  soon 
as  the  effusion  has  left  the  joint,  all  will  have  been  gained  in  the 
reduction  of  the  fracture  that  can  be  gained  by  this  method. 

Aspiration  of  the  knee-joint  by  means  of  a  narrow  knife  incision 
or  by  means  of  a  large-sized  trocar  is,  if  done  under  strictly  anti- 
septic precautions,  and  forty-eight  hours  after  the  fracture,  often 
satisfactory  in  immediately  removing  the  bulk  of  the  effusion;  if 
firm  compression  is  then  made,  it  effectually  prevents  the  reac- 
cumulation  of  fluid. 

Maintenance  of  Reduction  until  Union  is  Satisfactory. — At  the 
end  of  about  four  or  six  weeks  from  the  injury  union  will  be  found. 
All  fluid  will  have  left  the  joint.  The  retentive  straps  and  coapta- 
tion splints  may  now  be  removed.  The  leg  should  be  immobilized 
by  means  of  a  plaster-of- Paris  splint  extending  from  just  below  the 


Vvj,.  641. —  Old  fracture  of  patella  ;  great  separation  of  fragments.  Condyles  of  the  femur 
are  prominent  in  between  fragments.  Leg  was  useful,  but  weak.  ^,  The  lower  fragment ; 
B,  the  condyles  of  the  femur ;   C,  the  upper  fragment. 


swell  of  the  calf  to  the  groin.  This  sphnt  is  spHt  on  the  side  or 
posteriorly  and  arranged  as  a  removable  dressing.  Proper  bath- 
ing is  facilitated.     This  enables  the  masseur  to  work. 

The  removable  splint  is  made  thus:  A  light  weight  plaster-of- 
Paris  roller  bandage  is  applied  to  the  properly  protected  leg  from 
above  the  ankle  to  the  groin.  It  is  split  in  the  median  line  its 
whole  length  before  the  plaster  has  quite  hardened.  It  is  sprung 
off  the  leg.     After  it  is  hard  a  narrow  strip  of  leather,  upon  which 

are  fastened  lacing  hooks,  is  stitched  to  each  cut  edge.     This 
30 


466 


FRACTURES    OF   THE    PATELLA 


splint  may  now  be  sprung  on  the  limb  and  laced  snugly  in  posi- 
tion. A  leather  splint  may  be  similarly  made  from  a  plaster  cast 
and  mold  of  the  limb.  As  soon  as  union  is  firm,  the  patient 
should  be  up  and  about  with  the  light  removable  fixation  splint 
applied,  walking  with  the  aid  of  crutches. 

Fixation  (prevention  of  flexion  and  extension)  on  walking  is  to 
be  maintained  for  at  least  six  months  after  the  injury.  Protect- 
ing the  knee  thus  when  walking  for  this  period  of  six  months  does 
not  preclude  active  movements  of  the  knee  when  not  bearing 


F;g.  642. — Case:  Fracture   of  the  patellae.    Moderate  separation   of   the  fragments  of  each 
knee-joint.     Useful  legs. 


weight  upon  the  limb.  At  the  end  of  that  time  the  patient  may 
be  allowed  to  go  about  with  a  cane  and  a  snugly  fitting  roller  ban- 
dage (see  Fig.  640).  This  bandage  should  be  made  of  medium 
weight  flannel,  cut  straight  with  the  weave  and  not  on  the  bias. 
The  bandage  should  be  applied  from  the  middle  of  the  calf  of  the 
leg  to  the  middle  of  the  thigh  when  the  leg  is  completely  extended. 
As  the  patient  becomes  confident  of  his  strength,  the  cane  need  not 


EXPECTANT   TREATMENT. 


467 


be  carried.  Sudden  movements  are  to  be  avoided.  At  the  end 
of  eight  or  ten  months,  varying  with  the  individual  case,  all  sup- 
port may  be  omitted  from  the  knee. 


Fig.  643. — Transverse  fracture  of  the  patella,  its 
middle  remarkably  clean  cut. 


Fig.  644. — Transverse  fracture  ot  the  patella, 
union  solid. 


Fig.  649. 

Figs.  64S-'549-— Upper  third.     Types  of  fracture  of  the  upper  third  of  the  patella.     Note  tilting  of  frag- 
ments. 


The  Restoration  of  the  Function  of  the  Joint. — From  the  day  of 
the  injury  daily  massage  to  the  whole  limb  is  important.  It  main- 
tains the  muscles  in  good  tone.    It  prevents  adhesion  of  the  frag- 


Fig.  654. 

Figs.  650-654. — Types  of  fractures  of  the  lower  third  of  the  patella.     The  figure  at  the  bottom  is  an 

unusual  fracture  of  the  anterior  portion  of  the  lower  third. 


Fig.  657.  Fig.  658. 

Figs.  655-658. — Illustrating  types  of  tilting  or  displacement  of  the  fragment  in  a  fracture  of  the  patella. 


EXPECTANT   TREATMENT 


469 


ments  to  the  tissues  about  the  condyles  of  the  femur,  a  not  un- 
common cause  of  ankylosis  of  the  joint.  It  facilitates  the  absorp- 
tion of  the  effusion  of  blood  and  synovial  fluid.  After  the  fourth 
week  daily  passive  motion  is  to  be  instituted ;  at  first  very  slight 


Fig.  661. 
Figs.  6sg-66i. — Fracture  in  lower  third  of  patella.     Note  comminution  of  lower  fragment. 

indeed,  barely  two  or  three  degrees.  If  the  relative  position  of  the 
fragments  is  not  altered  perceptibly  by  this  passive  motion  and 
lasting  pain  is  absent,  it  may  be  persisted  in  with  regularly  increas- 
ing amounts.  At  the  expiration  of  eight  or  ten  weeks  active  mo- 
tion at  the  knee-joint  may  cautiously  be  allowed.  The  appear- 
ance of  persistent  and  increasing  tenderness,  sensitiveness,  or  pain, 


470 


FRACTURES   OF  THE   PATELLA 


and  increasing  separation  of  the  fragments  are  the  indications  to 
diminish  or  cease  passive  and  active  motions. 

Summary  of  the  Treatment  of  Fracture  of  the  Patella  by  the 
Expectant  or  Non-operative  Method. — During  four  weeks  fixation 


Fig.  662. 


Fis.  663. 


Fig.  664. 
Fig.  662. — Comminuted  lower  fragment  of  patella.     Fig.  663. — Comminuted  fragments  between 
the  main  fragments.     Fig.  664. — Much  comminuted  fracture  of  the  patella.     Best  treated  by  an  encir- 
cling absorbable  suture  to  bring  fragments  together. 


of  the  knee,  elastic  compression,  douching,  massage,  the  thigh 
flexed  slightly  on  pelvis,  the  leg  extended,  retentive  straps,  coap- 
tation splints,  are  the  measures  employed.    At  the  fourth  or  sixth 


OPE;n    fracture    of   the    PATELIvA 


471 


week  remove  all  apparatus,  apply  removable  splint,  allow  walking" 
with  crutches,  and  use  daily  passive  motion.  At  the  eighth  week, 
discard  crutches,  use  cane,  and  permit  limited  daily  active  motion. 
At  the  sixth  month  discard  splint,  apply  flannel  bandages,  and 


Fig.  665. 


Fig.  667. 

Figs.  665-667.— After  suturing  fracture  of  the  patella  by  wire,  the  old  operation.     Note  the  lack  of 
exact  approximation  upon  the  joint  side  of  patella. 


discard  cane.     At  the  eighth  to  the  tenth  month,  remove  all  sup- 
port. 

Open  Fracture  of  the  Patella. — This  is  a  very  serious  injury, 
because  one  of  the  largest  synovial  cavities  of  the  body  is  exposed 
to  infection.  It  is  safest  and  wisest  to  lay  open  the  knee-joint, 
to  thoroughly  irrigate  it  with  a  solution  of  corrosive  sublimate 
(i :  10,000),  and  then  with  a  sterilized  normal  salt  solution.  All 
blood-clots  should  be  carefully  wiped  away.  All  loosely  attached 
fragments    of    bone    should    be    removed.     Particular   attention 


472 


FRACTURES   OF   THE   PATELLA 


should  be  paid  to  the  posterior  parts  of  the  joint,  behind  the  con- 
dyles of  the  femur.  It  will  be  found  convenient  in  cleaning  these 
parts  first  to  flush  the  joint  with  sterile  salt  solution  and  to  flex 
and  to  extend  the  knee.  All  parts  of  the  joint  posteriorly  are 
thus  likely  to  be  thoroughly  flushed.  The  fragments  should  be 
approximated  and  sutured  by  some  absorbable  suture.  The  skin- 
wound  should  be  closed.     The  knee-joint  should  be  immobilized 


Fig.  668. — Old  fracture  of  the  patella  with  great  separation  and  retraction  of  the  fragments  and  rupture 
of  the  patella  tendon  or  ligament.     Note  atrophy  of  the  patellar  fragments. 


Fig.  669. — Old  fracture  of  the  patella.     Note  absence  of  bony  union  of  unreduced  fragments. 

in  a  posterior  wire  splint  and  side  splints  or  in  a  plaster-of- Paris 
splint. 

Prognosis. — Ordinarily,  an  individual  should  not  follow  his 
occupation  for  about  six  weeks  to  two  months  after  a  fracture  of 
the  patella — i.  e.,  unless  the  occupation  can  be  conducted  with 
a  leg  held  stiffly  at  the  knee.  The  functional  usefulness  of  the 
limb  and  not  anatomical  considerations  should  be  the  chief  crite- 
rion in  determining  the  result  following  fracture  of  the  patella. 
If  a  man  can  earn  his  living  as  before  the  accident  without  local 
discomfort  or  hindrance,  he  possesses  a  useful  limb.  It  makes 
little  difference  if  there  is  a  slight  separation  of  the  fragments  or  a 


Fig.  670. 


Fig.  671. 


Fig.  672. 


Fig.  673. 


Fig.  674. 

Figs.  670-674. — Types  of  old  fracture  of  the  patella.     Note  the  irregular  joint  surfaces  on  the  under 

side  of  patella. 


473 


474  FRACTURES   OF   THF   PATELLA 

suggestion  of  a  limp  or  slight  atrophy  of  the  thigh  and  calf  muscles ; 
these  conditions  are  all  to  be  accepted  as  part  of  the  irreparable 
damage,  and  are  trivial.  In  nonoperative  cases  the  union  is 
usually  fibrous  although  it  may  be  bony.  The  interval  between 
the  fragments  may  amount  to  five  or  six  inches.  The  approxi- 
mation of  the  fragments  of  the  patella  is  not  evidence  of  strength, 
for  the  fibrous  bond  of  union  may  be  much  narrower  than  the 
fractured  surface  and  very  thin,  and  thus  easily  ruptured.  The 
usefulness  of  the  limb  after  fracture  of  the  patella  is  not  dependent 
upon  any  one  factor,  either  the  kind  of  union  or  the  extent  of  the 
separation  of  the  fragments  of  bone.  There  are  usually  no  adhe- 
sions of  the  upper  fragment  to  the  femur;  but  injury  to  the  bursa 
under  the  quadriceps  may  cause  troublesome  adhesions  upon  the 
anterior  surface  of  the  thigh.  Full  flexion  is  a  common  result, 
but  there  is  often  limitation  of  active  extension.  There  almost 
always  remains  a  little  joint  stiffness,  despite  both  massage  and 
active  and  passive  motion;  this,  unless  due  to  fibrous  adhesions, 
disappears  gradually.  The  majority  of  cases  of  fracture  of  the 
patella  under  careful  nonoperative  treatment  will  secure  a  useful 
limb.  A  patella  once  fractured  and  having  united  by  fibrous  or 
bony  union  may  be  broken  through  the  callus  of  the  healed  frac- 
ture or  in  an  entirely  different  fracture  from  the  first  break. 

Results  after  Fracture  of  the  Patella.— In  a  series  of  forty- 
seven  cases  of  fracture  of  the  patella  treated  at  the  Massachusetts 
General  Hospital,  occurring  between  the  ages  of  eleven  and  sixty- 
five  years,  four  were  over  fifty  years,  thirteen  were  under  twenty- 
five  years,  twenty-nine  were  between  twenty-five  and  forty-five 
years,  one  was  forty-seven  years  old;  practically,  a  young  adult 
series.  Of  this  series  of  forty-seven  cases  ten  were  treated  by 
operation  and  the  remainder  by  the  expectant  method.  These 
cases  are  not  mentioned  in  this  connection  to  compare  methods 
of  treatment,  but  to  determine  the  condition  of  the  knee  a  long 
time  after  the  injury.  As  a  matter  of  fact,  there  appeared  no 
greater  freedom  from  the  symptoms  complained  of  among  the 
cases  operated  on  than  among  those  unoperated.  The  results,  as 
carefully  recorded  in  these  forty-seven  cases,  suggest  some  of  the 
difficulties  that  patients  experience  after  fracture  of  the  patella. 


RESULTS  AFTER  FRACTURE  OF  THE  PATELLA 


475 


The  detailed  reports  of  these  cases,  from  one  and  one-half  to  ten 
and  one-half  years  after  treatment  ceased,  show  that  about  twenty- 
have  as  good  a  leg  as  before  the  accident.     The  remaining  twenty- 


Fig.  675. — Fracture  of  the  patella,  showing  fascia  lying  over  broken  surface.     Smaller  figure"  shows 
one  portion  of  fascia  picked  up  in  forceps. 


seven  cases  complain  of  limitation  of  motion  at  the  knee-joint,  that 
the  knee  creaks  in  walking,  that  it  feels  stiff,  aches,  and  burns  at 
times.  The  leg  is  said  to  be  weak,  and  is  troublesome  in  going  up 
and  down  stairs — stepping  up  is  especially  difficult;  kneeling  is 
painful ;  stepping  upon  irregular  surfaces  is  painful ;  running  with 
the  same  freedom  as  before  the  accident  is  impossible;  the  knee 
often  gives  way  in  walking  and  causes  a  fall ;  the  patient  can  not 
jump  as  before  the  accident,  and  walks  with  a  shght  hmp.     Pain 


476 


FRACTURES    OF   THE    PATELLA 


is  present  in  or  about  the  knee  in  damp  weather  and  after  unusual 
exertion. 

In  a  second  series  of  cases  of  fracture  of  the  patella  treated 
at  the  Massachusetts  General  Hospital  the  end-results  have  been 
studied  by  Ouinby  and  are  suggestive.     Thirty  cases  were  exam- 


Fig.  676. — Note  the  sutures  carried  through  the  fascise  torn  about  knee  in  fracture  of 
patella.  None  of  the  sutures  enter  the  knee-joint.  This  method  of  suture  is  efficient  in 
approximating  most  fractured  patellae. 


ined.  Of  these  30  cases,  24  were  sutured  and  but  6  treated  expec- 
tantly. Serviceable  knees  were  obtained  in  84.5  per  cent,  of  the 
sutured  cases  and  in  66.5  per  cent,  of  the  unsutured  cases. 
Although  these  groups  of  cases  are  small,  yet  the  general  impres- 
sions derived  from  a  study  of  the  individual  cases  are  extremely 
suggestive — viz.,  (a)  certain  annoying  difhculties  persist  after 
treatment  by  either  method,  and  (b)  the  operative  method  is  to 
be  preferred  in  selected  cases. 


OPERATIVE    TREATMENT 


477 


Operative  Interference  in  Recent  Closed  Fractures  of   the 
Patella. — In  deciding  whether  a  given  case  should  be  treated  by 


Fig.  677. — Fracture  of  patella.     Note  insertion  of  sutures  so  as  to  avoid  joint  cavity  and  yet 
so  as  to  snug  the  fragments  together  when  sutures  are  drawn  taut  (after  Blake). 


Fig.  678. — Fracture  of  patella.     Note  sutures  placed  and  tied.     The  skin  incision  remains  to 
be  closed  (after  Blake). 


operation  or  not,  the  following  considerations  should  be  carefully 
weighed :  A  closed  fracture  of  the  patella  does  not  in  itself  endan- 


478 


FRACTURES    OF    THS    PATEIvLA 


ger  life.  It  may  be  treated  by  the  conservative  method  without 
added  risk.  If  properly  treated,  the  result  will  often  be  satis- 
factory as  far  as  the  functional  usefulness  of  the  knee  is  con- 
cerned. The  operative  method  consumes  less  time  in  convales- 
cence and  an  excellent  result  is  achieved,  but  operation  exposes 
to  the  danger  of  sepsis.  If  sepsis  results,  the  following  conditions 
are  imminent :  A  stifiF  knee,  amputation  of  the  thigh,  and  possibly 
death  from  septic  infection.  Whether  operation  shall  be  done  or 
not,  therefore,  depends  upon  the  degree  of  safety  with  which  it 


Fig.  679. — Case  :  Freshly  fractured  right  patella  sutured  with  chromicized  catgut.     Result 
after  eight  weeks.     Note  flexion  of  leg  to  a  right  angle  ;  line  of  incision  (Warren). 


can  be  performed.  It  is  the  surest  method  of  securing  perfect 
apposition  and  bony  union.  It  should  be  undertaken  only  by 
surgeons  of  exceptional  judgment  and  great  skill,  who  have  at 
command  skilled  assistants,  and  who  can  work  under  the  most 
rigid  aseptic  conditions.  The  acute  symptoms  should  be  allowed 
to  subside  before  operation.  The  tissues  require  time  to  recover 
from  the  acute  trauma.  The  operative  treatment  should  be 
confined  to  healthy  individuals  under  sixty  years  of  age;  to 
fractures    with   a    distinct    separation    of    the   bony   fragments 


OPERATIVE    TREATMENT  479 

and  extensive  lateral  fascial  tears  (the  fascial  tears  may  be 
recognized  by  joint  distention  and  localized  bulging) ;  to  cases 
presenting  great  joint  distention  that  does  not  disappear  quickly. 
It  should  be  seriously  considered  if  the  individual's  occupation  is 
arduous  and  necessitates  much  standing  or  walking.  The  patient 
should  be  informed  as  to  the  probable  outcome  by  the  two  methods 
of  treatment.  The  danger  to  life  and  limb  should  be  fairly  stated. 
It  should  be  remembered  that  the  power  of  extension  of  the  leg  is 
not  materially  limited  by  a  transverse  fracture  of  the  patella  in 
which  the  tearing  of  the  lateral  fascia  is  absent.  Only  in  direct 
proportion  to  the  extent  of  the  lateral  fascial  tear  is  there  limita- 
tion of  the  power  of  extending  the  leg  upon  the  thigh.  In  open 
fractures,  m  refracture,  and  in  cases  of  impaired  function  from 
long  fibrous  union  or  from  adhesions  of  the  patella  or  from  badly 
united  patellae  mechanically  impeding  the  movements  of  the  joint, 
operation  is  always  indicated.  The  working-man  who  wants  to 
get  to  work  should,  under  the  conditions  previously  stated,  have 
his  patella  sutured,  for  he  will  go  to  work  quicker  and  have  a 
better  knee-joint  than  by  any  other  method  of  treatment. 

Method  of  Operation. — The  joint  and  the  fractured  bones  are  to 
be  thoroughly  exposed  by  a  transverse  or  longitudinal  incision. 
All  clots  should  be  thoroughly  washed  or  sponged  out.  Any 
loose  small  fragments  of  bone  should  be  removed.  In  almost  all 
cases  a  rather  dense  fascia  will  be  found  overlapping  the  broken 
surfaces  of  the  two  fragments  (especially  is  this  seen  in  a  trans- 
verse fracture).  These  bits  of  overlapping  tissue  or  curtains  of 
tissue  should  be  retracted  and  removed  or  utilized  in  suturing  the 
fragments  (see  Fig.  675).  Whether  silver  wire  is  employed  to 
suture  the  bone  directly  or  whether  an  absorbable  material  is 
used  to  suture  the  soft  parts  seems  of  little  consequence  as  long 
as  all  fascial  tears  are  sutured  and  the  bony  fragments  are  ap- 
proximated. The  weight  of  opinion  to-day  is  in  favor  of  absorb- 
able sutures.  Closure  of  the  joint  without  drainage  and  immo- 
bilization in  the  extended  position  followed  by  the  treatment 
already  mentioned  are  indicated  (see  Fig.  679). 

The  Restoration  of  the  Function  of  the  Joint  Following  the  Opera- 
tive Treatment. — After  suture  of  the  patella,  massage  and  gentle 
passive  motion  should  be  begun  at  the  end  of  two  weeks.     At  the 


48o 


Fractures  of  the  patella 


end  of  three  weeks  the  patient  may  go  about  with  the  knee  pro- 
tected by  a  hght  stiff  dressing.  After  about  six  weeks  to  two 
months  a  flannel  bandage  and  a  cane  will  be  all  the  protection 
needed  to  the  knee.  At  the  end  of  three  months  the  knee  should 
be  almost  functionally  perfect. 

Old  Fracture  of  the  Patella. — Occasionally  it  is  necessary  to 
repair  a  fracture  of  the  patella  which  has  been  broken  same  time 
previously,  several  months  perhaps.  A  varying  amount  of  diffi- 
culty attends  the  attempt  to  bring  the  upper  fragment  down  to  the 


Fig.  6So. — Old  fracture  uf  the  right  ijutella.     Xote  the  retracted  fosition  of  tlie  upier  fragment  of  the 

right  patella. 

lower  fragment.  Obviously  an  incision  is  necessary.  Three  ways 
of  accomplishing  this  have  been  found  effective;  (a)  by  a  trans- 
verse incision  of  the  fascia  over  the  rectus  and  of  the  rectus  itself; 
(6)  by  several  lateral  transverse  incisions  either  alone  or  together 
with  a  median  transverse  incision  of  the  thigh  fascia;  (c)  by  reflect- 
ing a  flap  of  the  quadriceps  fascia  downward  and  so  suturing  it 
as  to  bridge  the  gap  between  the  upper  and  lower  fragments  of  the 
patella. 

By  this  latter  procedure  (c)  little  attempt  is  made  to  approxi- 
mate the  bony  fragments,  but  the  gap  is  filled  by  a  strong  fascia. 


CHAPTER  XIV 

FRACTURES  OF  THE  LEG 

Anatomy. — The  following  structures  may  be  palpated:  The 
internal  and  external  tuberosities  of  the  tibia,  the  whole  of  the 


Fig.  68i — Middle  of  the  patella,  tuber- 
cle of  the  tibia,  and  midpoint  between  the 
malleoli  all  lie  in  the  same  straight  line  as 
the  leg  rests  naturally. 


Fig.  682. — Fracture  of  the  tibia,  low  down 
(Warren  Museum  specimen). 


external  tuberosity  being  subcutaneous;  the  broad  anterior  and 

inner  surface  of  the  tibia,  which  forms  the  shin,  downward  to  the 
31  481 


482 


FRACTURES   OF   THE   LEG 


internal  malleolus;  the  sharp  crest  of  the  tibia  throughout  its 
whole  length ;  the  head  of  the  fibula,  an  inch  below  the  top  of  the 
tibia ;  a  little  of  the  shaft  of  the  fibula  below  the  head  and  the  at- 
tachment of  the  biceps  tendon ;  the  lower  third  of  the  fibula  which 
is  subcutaneous.  The  tubercle  of  the  tibia  is  distinctly  felt  on  the 
anterior  surface  of  the  upper  end  of  the  tibia.  It  is  one  inch  from 
the  articular  surface,  and  marks  the  lowest  limit  of  the  upper 


Fig.  6S3. —  Fracture  of  bolh  bones  of 
the  leg,  high  up  (Warren  Museum  speci- 
men). 


Fig.  6S4. — Old  fracture  of  tibia.  Union 
in  malposition  ;  section  of  bone  showing 
relative  position  of  fragment  at  seat  of 
union  (Warren  Museum  specimen). 


epiphysis  of  the  tibia.  Into  it  is  inserted  the  patellar  tendon. 
The  shaft  of  the  tibia  arches  slightly  forward.  The  shaft  of  the 
fibula  arches  slightly  backward.  The  broad  inner  malleolus  is 
higher  than  the  outer  malleolus,  and  more  to  the  front  of  the  leg. 
The  outer  malleolus  is  narrow.  The  posterior  edges  of  the  two 
malleoli  are  in  about  the  same  plane.  The  anterior  edge  of  the 
external  malleolus  is  about  an  inch  behind  the  anterior  edge  of  the 
internal  malleolus.     The  narrowest  part  and  the  weakest  place  in 


=  a 

O   rt   (U 

o    . 

13!^ 

S.5,o.£ 

fr,'^ 

483 


484 


FRACTURES    OF   THE    LEG" 


the  tibia  is  at  the  junction  of  the  lower  and  middle  thirds  of  the 
bone.  In  the  normal  leg  the  middle  of  the  patella,  the  tendon  of 
the  patella,  and  the  midpoint  of  the  ankle  are  in  the  same  straight 
line  (see  Fig.    68i). 

General  Observations. — Fractures  of  the  tibia  and  fibula  may- 


Fig.  686.- 


-Fracture  of  both  bones  of  the  leg;  displacement  of  upper  fragments  downward 
and  inward  ;  union  (Warren  Museum,  specimen  8303). 


occur  at  any  point,  depending  upon  the  seat  and  direction  of  the 
fracturing  force.  If  the  force  is  indirect,  the  fracture  of  the  two 
bones  will  be  at  different  levels.  If  the  fracture  is  high  up,  the 
knee-joint  may  be  involved  or  the  popliteal  vessels  and  peroneal 
nerve  may  be  implicated.     If  the  fracture  is  low  down,  the  ankle- 


GENERAL   OBSERVATIONS 


485 


joint  may  be  involved.  The  high  fracture  of  the  tibia  is  usually 
transverse.  The  low  fracture  of  the  tibia  is  usually  oblique.  The 
common  seat  of  fracture  is  at  about  the  junction  of  the  middle 
and  lower  thirds  of  the  leg.  The  line  of  the  fracture  is  an  oblique 
one,  extending  from  above  and  behind  downward  and  forward 
through  the  tibia.  The  fibula  is  fractured  a  little  higher  than  the 
tibia.  If  the  force  is  considerable  and  the  sharpness  of  the  frag- 
ments great,  the  overlying  skin  may  be  lacerated,  an  open  or  in- 
fected fracture  resulting.  The  upper  and  lower  epiphyses  of  the 
tibia  may  be  separated;  these  are,  however,  rare  injuries.     The 


Fig.  687.— Method  of  measuring  the  length  of  the  tibia  from  the  internal  tuberosity  to  the 

internal  malleolus. 


tibia  and  fibula  may  be  fractured  separately.  In  such  cases  the 
unbroken  bone  serves  as  a  splint  for  the  fractured  one.  The  dis- 
placement in  these  latter  fractures  is  slight. 


INJURY  TO  THE  TIBIAL  TUBERCLE 

The  beak-shaped  process  of  the  tibia  probably  has  its  own  bony 
nucleus  appearing  at  eleven  years.  This  nucleus  merges  at  fifteen 
years  with  the  upper  tibial  epiphysis. 

It  is  not  very  unusual  in  young  athletic  adults  to  find  a  start- 
ing of  the  upper  epiphysis  of  the  tibia  as  illustrated  in  Fig. 
685.     It  has  been  demonstrated  recently  that  many  apparently 


486 


FRACTURES   OF   THE   LEG 


trivial  injuries,  such  as  violent  contraction  of  the  quadriceps  ex- 
tensor muscle,  a  blow  to  the  region  of  the  tubercle  of  the  tibia, 
result  in  partial  separations,  with  or  without  some  displace- 
ment of  the  tongue-shaped  portion  of  the  upper  epiphysis  of  the 
tibia,  or  actual  separation  of  an  independent  bony  center  for  the 
tubercle  of  the  tibia.  The  trauma  necessary  to  produce  this 
lesion  may,  therefore,  be  either  direct  or  indirect.  In  vouth  in- 
jury to  this  part  results  in  a  starting  of  this  epiphysis,  while  in- 
jury in  adult  life  is  more  likely  to  cause  a  fracture  of  the  tongue- 
like portion    of    the    epiphysis.      Clinically,   slight    swelling  and 


Fig.  6S8. — Fracture  of  both  bones  of  the  left  leg.  Comparative  height  of  knees  to  show 
shortening  of  leg.  The  patient  is  sitting  with  knees  flexed  to  a  right  angle  (after  Van 
Lennep). 


tenderness  in  the  region  of  the  tibial  tubercle  and  pain  upon  ex- 
tension are  the  chief  signs. 

If  the  local  symptoms  following  an  injury  to  the  tibial  tubercle 
do  not  disappear  under  appropriate  treatment,  or  if  the  difficulty 
goes  untreated,  the  condition  may  be  thought   to  be  a  tumor  of 


METHOD    Olf    EXAMINATION  487 

some  kind,  a  bursitis,  tuberculosis  localized,  an  epiphysitis,  or  a 
traumatic  periostitis. 

Osgood  writes: 

"At  the  time  of  the  injury  there  is  felt  acute  pain  in  the  knee 
referred  to  below  the  patella.  There  is  often  slight  swelling,  either 
general  or  pretty  definitely  localized  over  the  region  of  the  tuber- 
cle. There  is  distinct  tenderness  at  this  point.  The  ability  to 
use  the  leg  is  only  slightly  diminished,  and  the  acute  pain  is  soon 
replaced  by  a  feeling  of  weakness  on  strong  exertion.  Sharp 
pain  is  present  on  violent  extension  or  extreme  flexion  of  the 
leg,  and  the  patient  usually  consults  the  surgeon  because  of  this 
pain,  the  annoying  weakness,  and  the  continued  localized  swell- 
ing or  tenderness. 

"  The  condition  presents  no  complete  loss  of  function,  but  a 
severe  handicap  to  the  active,  athletic  life  which  this  class  of 
patients  wish  to  lead." 

Complete  or  partial  immobilization  of  the  knee-joint  upon  the 
injured  side  for  a  longer  or  shorter  time  will  ordinarily  suffice  to 
effect  a  cure  of  the  difficulty.  If  protective  methods  fail  after 
fair  trial,  operative  pegging  or  removal  of  the  fragments  is  to  be 
considered. 

Patella. 


Fig.  689. — Case:  Fresh  fracture  of  the  leg  (both  bones).  Characteristic  deformity.  Note 
normal  position  of  patella,  with  the  foot  lying  on  its  outer  side.  Prominence  of  upper  frag- 
ment. Compare  this  with  figure  557  of  a  fracture  of  the  thigh  in  which  the  patella  does  not 
look  upward. 


Examination  of  a  Fractured  Leg. — It  is  sometimes  extremely 
difficult  to  detect  a  fracture  of  the  leg.  It  is,  therefore,  important 
that  a  systematic  examination  should  be  made  immediately  after 
the  injury.  Deformity  will  ordinarily  be  apparent  upon  inspec- 
tion (see  I'ig.  689).    Gentle  manipulation  will  suffice  to  satisfy  one  of 


488 


FRACTURES   OF   THE   LEG 


the  existence  of  a  fracture,  particularly  if  both  bones  are  broken. 

An  open  fracture  will  be  evident  if  a  wound  exists  in  the  skin  near 

the  seat  of  fracture.  In  taking  hold  of 
the  leg  for  examination  or  for  moving 
the  leg  it  should  not  be  grasped  lightly 
by  a  few  fingers,  but  by  the  whole 
hand,  firmly,  as  one  grasps  an  ax- 
handle  in  chopping  wood;  not  as  one 
lifts  a  lead-pencil  from  the  table.  The 
leg  should  be  so  raised  in  making  the 
examination  that  there  is  absolutely 
no  risk  of  converting  the  closed  frac- 
ture into  an  open  one.  In  order 
to  guard  against  this  the  assistant 
should  grasp  the  foot  at  the  ankle 
and  make  gentle  but  strong  trac- 
tion in  the  long  axis  of  the  leg  as 
This  care  in  examination  will  cause  the 


Fig.  6qo — Fracture  of  the  tibia, 
oblique  and  high  up.  Almost  no  di.s- 
placement  (Massachusetts  General 
Hospital,  1235.     X-ray  tracing). 


the  whole  leg  is  raised. 


Femur. 


Tibia. 


Fibula. 


Fig.  691. — Fracture  of  the  external  tuberosity  of  the  tibia  (Massachusetts  General  Hospital, 

1242.    X-ray  tracing). 


patient  a  minimum  amount  of  pain.     Crepitus  is  not  the  only 
thing  that  is  to  be   sought  at  the  examination.      The   freedom 


METHOD    OF    EXAMINATION 


489 


of  any  abnormal  mobility  should  be  noticed,  as  well  as  the  direc- 
tion of  the  motion,  the  ease  with  which  reduction  is  possible,  and 
the  liability  to  recurrence  of  the  deformity.  If  there  is  any  doubt 
as  to  the  seat  or  extent  of  the  fracture,  the  examination  should  be 
made  with  the  assistance  of  an  anesthetic.  The  temporary  dress- 
ing may  be  applied  at  this  time.  The  bones  should  be  palpated. 
While  an  assistant  steadies  the  knee-joint  the  surgeon,  grasping 
the  lower  part  of  the  leg,  attempts  motion  in  each  direction.     Sim- 


Fig-  692.— Longitudinal  Assuring  of 
tibia  from  blasting  accident.  Front  view 
(X-ray  tracing). 


Fig.  693. — Longitudinal  Assuring  of 
tibia  from  blasting  accident.  Lateral  view. 
Same  as  figure  692  (X-ray  tracing). 


ply  raising  the  leg  and  attempting  motion  in  an  anteroposterior 
direction  is  not  sufficient;  a  fracture  of  the  tibia,  if  transverse, 
might  remain  completely  locked  except  upon  lateral  movement. 
The  tibia  should  be  measured  (see  Fig.  687)  from  the  knee-joint 
line,  at  the  upper  border  of  the  internal  tuberosity,  to  the  lower 
edge  of  the  internal  malleolus  to  determine  shortening.  Shorten- 
ing of  the  leg  may  be  roughly  estimated  after  union  of  the  bones  by 
comparing  the  height  of  the  two  knees  while  the  soles  of  the  feet 
rest  upon  the  floor  (see  Fig.  688).  The  measurement  should  be 
compared  with  that  of  the  uninjured  tibia.  It  is  often  difficult 
in  fractures  near  the  ankle  to  palpate  the  internal  malleolus,  on 


490 


FRACTURES    OF    THE    I.EG 


account  of  swelling.  Deep  pressure  with  the  thumb  will  detect 
it.  Inquiry  should  be  made  as  to  whether  either  tibia  has  ever 
been  fractured  previously.  The  pulse  should  be  felt  for  in  the 
posterior  tibial  and  dorsalis  pedis  arteries  to  be  sure  that  the 
large  vessels  of  the  leg  are  intact. 


Fig.  694.- 


-High  fracture  of  both  bones 
of  the  leg. 


Fig.  695. 


-High  fracture  of  tibia  and  fibula,  antero- 
posterior view.     See  Fig.  696. 


7-  T 

Fig.  696. — Same  as  Fig.   095,  lateral  view. 

S5n3iptoms. — Ordinarily,  the  presence  of  pain,  deformity,  ab- 
normal mobility,  crepitus,  and  loss  of  use  of  the  leg  will  be  the  evi- 
dences of  fracture.  If  the  fracture  is  of  the  tibia  or  fibula  alone 
and  transverse  without  much  displacement,  localized  tenderness 
upon  pressure  and  swelling  will  be  the  only  signs.  It  is  important 
to  remember  the  backward  bowing  of  the  fibula  in  attempting 


SYMPTOMS 


491 


to  localize  by  palpation  the  tender  point  of  the  fracture  of  that 
bone. 

The  deformity  is  due  to  the  displacement  of  the  upper  fragment 
forward  and  of  the  lower  fragment  upward  and  backward.  If  the 
fracture  is  oblique,  this  displacement  will  be  considerable.     The 


Fig.  697. 


Fig.  6g8. 


Fig.  699. 


Fig.  700.  Fit;.  7°^- 

Figs.  697-701. — Types  of  fracture  of  the  tibial  siiaft. 


lower  fragment  is  often  rotated  upon  its  longitudinal  axis,  so  that 
the  foot  rests  upon  its  side,  while  the  upper  fragment  remains 
undisturbed   by   rotation,    the    patella   looking   directly   upward 
(see  Fig.   689). 
The  swelling  will  vary.     It  may  be  extremely  slight  and  limited 


492 


FRACTURES    OF    THE    LEG 


to  the  seat  of  the  fracture  or  it  may  extend  over  the  entire  leg. 
The  maximum  swelling  of  the  leg  is  usually  reached  three  or  four 
days  after  the  accident.  If  the  fracture  was  caused  by  direct 
violence  and  the  fragments  of  bone  are  sharp,  the  soft  parts 
will  be  damaged  and  the  resulting  hemorrhage  and  swelling  will 
be   very   considerable. 


Fig.  702. 


Fig.  703. 


Fig.  704. — Note  changes   in   distal 
fragment. 

Figs.  702-705. — Types  of  fracture  of  the  tibia  and  fibula 


Fig.  705. — Note  light  shadow  of  distal  frag- 
ment of  tibia. 


Ecchymosis  of  the  skin  appears  in  from  twenty-four  to  forty- 
eight  hours  after  the  accident;  it  may  extend  over  the  whole  leg. 
Ecchymosis  from  a  sprain  is  localized  more  or  less  about  the  seat 
of  the  sprain;  that  from  a  fracture  is  often  extensive.     Blebs  or 


SYMPTOMS 


493 


vesicles  may  appear  near  the  fracture  during  the  first  week  if  the 
swelHng  is  great.  It  is  necessary  to  exercise  great  caution  in  the 
care  of  these  blebs,  that  they  do  not  become  infected. 


Fig.  706. — Fracture  of  tibia,  subperiosteal. 
Rather  rare. 


L  . 

Fig.  707.^ — Anteroposterior  view.  Botti 
bones  fractured  near  the  middle.  Considerable 
displacement  of  tibial  fragments.  A  longi- 
tudinal split  seen  in  the  fibula. 


Fig.  708. — Anteroposterior  view.  Both 
bones  fractured  at  middle.  Slight  displace- 
ment, little  comminution.  Important  in 
this  fracture  to  avoid  a  bending  backward 
or  forward  at  the  seat  of  fracture. 


Fig.  709. — Anteroposterior  view.  Both 
bones  fractured  near  the  middle.  Much 
displacement  laterally,  and  longitudinally. 
Comminution  of  tibia,  one  large  frag- 
ment seen.  Open  incision  indicated  in 
such  a  fracture. 


Fracture  of  the  shaft  of  the  fibula  may  be  very  obscure,  but 
pressure  upon  the  fibula  toward  the  tibia  will  elicit  pain  and 
crepitus.     In  separation  of  the  lower  epiphysis  of  the  tibia  the 


494 


FRACTURES    OF    THE    LEG 


preservation  of  the  normal  relations  between  the  malleoli  is  of 
considerable    diagnostic    importance. 


Fig.  710. 


Fig.  711. 


Fig.  712-  Fig.  713. 

Figs.  710-713. — Fractiu'e  of  the  fibula.    Types  of  fracture. 

Treatment. — For   purposes  of  treatment  fractures  of  the  leg 
are    arranged    into    several    distinct    groups,  viz. : 

1.  Fractures  with  little   or  no   swelling  or  displacement. 

2.  Fractures  with  considerable  swelling. 

3.  Fractures  with  a  displacement  of  fragments  difficult  to  hold 
corrected. 

4.  Open  fractures. 

The  indications  to  be  met  by  treatment  in  each  of  these  groups 


TREATMENT 


495 


are  correction  of  deformity,   immobilization  of  fragments,   and 
restoration  of  the  limb  to  its  normal  condition. 

Fractures  with  Little  or  No  Displacement  or  Swelling. — Fractures 


Fig.  714-— Transverse   fracture  of  both  bones   of  the  leg  close  above  the  ankle-joint.     Dis 
placement  of  the  foot  outward. 


Tibia 


Astragalus  |^g 


Os  talcis 


Fig.  715. — Type  of  fracture  neur  ankle-joint. 


of  the  tibia  alone  or  the  fibula  alone  are  properly  placed  in  this 
group.  Fractures  of  both  bones  occasionally  occur  with  Httle  or 
no  displacement  and  with  but  a  trifling  amount  of  swelling.  In 
these  cases  the  leg  should  be  elevated  for  ten  minutes  in  order  to 


496 


FRACTURES    OF    THE    LEG 


lessen  the  swelling.  The  foot,  leg,  and  lower  thigh  are  then 
bathed  with  soap  and  water,  and  thoroughly  dried  and  powdered. 
The  leg  being  properly  protected,  a  light  plaster-of-Paris  roller 
bandage  is  apphed  from  the  toes  to  the  middle  of  the  thigh.  (See 
Details  of  Plaster  Work.)  The  leg  is  to  be  kept  elevated  for  the 
first  week  by  at  least  two  or  three  pillows.  If  good  judgment  is 
exercised  in  the  subsequent  care  of  the  case,  the  placing  of  such  a 
fracture,  as  previously  indicated,  immediately  in  a  plaster-of-Paris 
splint  is  attended  by  no  risk.    The  danger  lies  in  too  great  pressure 


Tibia 


Tibia 


Astragal 


Fig.  716. — Type  of  fracture  ne:ir  ankle-joint.  Fig.  7i7- — Type  of  fracture  near  ankle. 


upon  the  circulation,  caused  by  the  increasing  swelling  of  the  leg 
within  the  unyielding  plaster  splint.  Pressure  sores  and  gangrene 
are  liable  to  result.  In  applying  the  splint  a  liberal  amount  of 
sheet  wadding  should  be  used.  The  condition  of  the  circulation 
should  be  noted  immediately  after  the  application  of  the  splint  and 
at  regular  intervals  thereafter  until  all  danger  from  undue  pressure 
has  ceased.  Evidences  of  too  great  pressure  are  persistent  or 
increasing  swelling  of  the  toes,  blueness  of  the  toes,  and  pain.  It 
is  well,  in  order  to  avoid  undue  pressure  upon  the  leg,  to  split  the 
plaster  the  entire  length  of  the  splint  before  it  has  quite  hardened. 
The  splint  loses  by  this  procedure  none  of  its  immobilizing  quali- 
ties, for  it  can  be  bandaged  or  strapped  tightly  together  again. 
Too  great  pressure  upon  the  circulation  can  then  be  immediately 


Fig.  718. — Fracture  of  both  bones  of 
the  leg  from  bullet-wound.  Characteristic 
comminution  of  the  bones.  Bullet  not  re- 
moved. Recovery  with  a  useful  leg  (X-ray 
tracing)  (Warren). 


\ 


/ 


Fig.  719. — Transverse  fracture  of  the 
tibia,  high.  Direct  violence.  Great  swell- 
ing of  leg.  Threatening  gangrene.  Free 
incisions.  Leg  saved.  Result  good.  Same 
case  as  figure  721  (Massachusetts  General 
Hospital,  1064.     X-ray  tracing)  (Scudder). 


Fibula 


Line  of  fracture 


Epiphyseal  line 
External  malleolus 


Internal  malleolus 
.  Astragalus 


tig.  720 — Fracture  of  the  internal  malleoKis  only,  i.  e.,  the  inner  part  of  the  lower  epiphysis  of  the 

tibia. 

32  497 


498. 


FRACTURES  OF  THE  LEG 


relieved  by  loosening  the  retaining  straps  or  bandage  and  thus 
opening  the  splint.  After  the  splint  has  been  on  the  leg  for  about 
a  week  and  a  half  or  two  weeks,  the  swelling  having  begun  to  sub- 
side, the  plaster  splint  will  become  loose  and  will  cease  to  hold  the 
fragments  firmly.     Unless  a  new  and  snug  splint  is  now  applied,  it 


Fig.  721. — Case:  Closed  fracture  of  the  left  Libia.  Hematoma.  Impairment  of  the  circu- 
lation. Free  incisions.  Evacuation  of  blood.  Relief  of  pressure.  Leg  saved.  Recovery 
(Scudder). 


BB^^^^^^^^^^'^^^^^i^^^^HI^^^^I^^^F     ** 


Fig.  722 — Fracture  of  the  leg.     Temporary  or  emergencj- dressing.     Application  of  the  pillow 
with  straps.     Open  end  of  the  pillow-case  at  the  foot. 

will  be  necessary  to  cut  out  a  strip  of  plaster  an  inch  or  more  wide 
from  the  old  splint  to  admit  of  tightening.  During  the  changing 
of  the  plaster  splint  the  leg  should  be  steadied  by  an  assistant 
while  it  is  thoroughly  washed  with  soap  and  water  and  bathed 
with  alcohol. 

Fractures  with   Considerable  Immediate  Swelling. — Many  frac- 


TREJATMENT 


499 


tures  are  not  seen  by  the  surgeon  until  two  or  three  hours  after 
they  have  occurred,  when  considerable  swelling  is  present.  As- 
sociated with  such  primary  swelling  there  will  be  laceration  of  the 
soft  parts  and  possible  extensive  injury  to  the  bone.  Blebs  filled 
with  clear  or  bloody  serum  may  be  present  about  the  seat  of  frac- 
ture. These  should  be  evacuated  after  the  part  has  been  rendered 
surgically  clean  by  washing  with  soap  and  water  and  corrosive 
sublimate  solution,  and  then  dressed  with  a  dry  antiseptic  powder, 
powdered  dermatol,  or  aristol.  Infection  may  take  place  through 
blebs.     Very  great  care  should  be  exercised  in  their  treatment. 


Fig.  723- — Fracture  of  the  leg. 


Pillow  and  side  splints  with  straps  and  towels.     Compare 
figure  724- 


Fig.  724. — Fracture  of  the  leg.     Temporary  or  emergency  dressing.     Pillow,  side  .splints,  and 
straps.     Pillow  held  by  shield-pins. 

Obviously,  it  is  unwise  immediately  to  apply  a  plaster-of-Paris 
splint  to  cases  in  which  there  are  many  blebs  and  much  swelling. 
The  swelling  of  the  leg  may  become  so  great  that  the  life  of  the 
limb  may  be  at  stake,  the  danger  from  impending  gangrene  be- 
coming imminent.  In  such  cases  the  skin  of  the  leg  becomes  tense 
and  shiny,  the  leg  feels  hard  and  board-like,  pain  may  be  extreme. 


500  FRACTURES    OF    THE    LEG 

and  the  toes  and  foot  become  slightly  blue.  The  hemorrhage,  be- 
ing confined  beneath  the  fascia  and  skin,  causes  pressure  upon  the 
circulation.  The  circulation  in  the  leg  is  thus  impeded.  Under 
such  circumstances  operation  is  necessary  in  order  to  relieve  ten- 
sion and  to  check  hemorrhage.  Incisions  in  the  long  axis  of  the 
limb  through  skin  and  fascia  will  be  followed  by  a  rapid  decrease 
in  the  swelling  of  the  leg  and  a  cessation  of  the  pain.  After  inci- 
sion, the  bleeding  vessels  found  should  be  ligated.  The  bones  may 
be  sutured  at  this  time  if  it  is  thought  wise.     If  these  wounds 


V 


Fig.  725. — Natural  position  of  leg  and  bones  resting  on  a  posterior  splint.     Note  seats  of  fracture  of 
tibia  and  fibula.     No  displacement  indicated. 


Fig.  726. — Same  as  figure  725.     Note  tliat  lifting  foot  and  distal  fragments  far  forward  causes  a  bow- 
ing of  leg  forward  and  gaping  open  posteriorly  of  the  fracture.     Cause  of  permanent  deformity. 

remain  aseptic,  they  may  be  closed  after  a  few  days  by  suture  or 
may  be  allowed  to  heal  openly.  This  method  of  treatment  will 
usually  result  in  saving  the  leg  (see  Figs.  719,  721).  If  the  circu- 
lation does  not  return  and  gangrene  is  imminent,  immediate  am- 
putation of  the  limb  well  above  the  fracture  at  the  lower  or  middle 
third  of  the  thigh  is  the  only  procedure.     Traumatic  gangrene  is 


TREATMENT 


501 


often  rapidly  followed  by  general  septic  infection.  It  is  best  to 
use  a  temporary  dressing  in  cases  in  which  there  is  great  initial 
swelling  of  the  leg. 

The  Temporary  Dressing. — The  Pillow  and  Side  Splints. — The 
leg  is  placed  on  a  pillow  covered  with  a  pillow-case;  straps  are 
placed  under  the  pillow  and  drawn  snugly  up  about  the  leg  (see 
Fig.  722).  The  edges  of  the  pillow  are  rolled  in  against  the  leg  for 
firmness.  Narrowly  folded  towels  are  placed  between  the  leg  and 
the  straps.  The  straps  are  then  drawn  tighter.  The  open  end  of 
the  pillow-case  is  folded  and  pinned  under  the  sole  of  the  foot. 
Three  pieces  of  splint  wood  are  introduced  between  the  pillow  and 
straps — one  is  slipped  underneath  and  one  upon  each  side  of  the 
pillow.     The  pillow  thus  serves  as  a  padding  for  the  box  formed 


Fig.  727.  — Padding  the  Cabot  posterior  wire  splint.     Applying  sheet  wadding.     The  shape 
and  proportions  of  the  Cabot  splint  are  apparent. 


by  the  splint  wood  (see  Fig.  723).  Ice-bags  may  be  conveniently 
placed  along  the  anterior  surface  of  the  leg  between  the  edges  of 
the  pillow.  They  relieve  pain  and  are  said  to  check  hemorrhage 
immediately  after  the  fracture.  If  greater  security  is  thought 
necessary,  the  pillow-case,  instead  of  having  its  sides  rolled  in, 
may  be  pinned  with  shield-pins  up  over  the  anterior  surface  of 
the  leg  (see  Fig.  724). 

This  temporary  dressing  is  left  in  place  for  a  week  or  a  week  and 
a  half.  The  swelling  will  then  have  partly  subsided.  If  at  this 
time  there  is  little  or  no  swelling  and  the  displacement  is  slight,  a 
plaster-of- Paris  splint  may  be  applied  as  a  permanent  dressing;  it 
is  split  or  not  as  circumstances  indicate.  If,  on  the  other  hand,  at 
the  end  of  a  week  or  a  week  and  a  half  it  is  desired  to  have  the 


502  FRACTURES    OF    THE    LEG 

fracture  open  to  inspection  and  more  directly  accessible  and  under 
the  eye  of  the  surgeon,  then  the  posterior  wire  and  side  splints 
should  be  applied. 

The  Permanent  Dressing  for  Fracture  of  ihe  Leg. — Several  im- 
portant things  are  to  be  kept  constantly  in  mind  in  placing  a  frac- 


Fig.  728. — Padding  the  Cabot  posterior  wire  splint:  (i)  With  sheet-wadding  (see  Fig. 
727);  (2)  with  a  cotton  roller  around  the  wire,  and  (3)  around  both  wires,  to  form  a  back  to 
the  splint. 

tured  leg  in  a  permanent  splint.  They  are  as  follows :  The  aline- 
ment  of  the  bones  of  the  leg  is  to  be  maintained ;  rotation  of  either 
fragment  upon  its  long  axis  is  to  be  avoided ;  the  foot  is  to  be  kept 
extended  to  a  right  angle  with  the  leg;  lateral  deviation  is  to  be 
avoided;  the  inner  side  of  the  great  toe,  the  middle  of  the  patella, 
and  the  anterior  superior  spine  of  the  ilium  should  be  in  one 


TREATMENT  503 

straight  line ;  anteroposterior  deformity  is  to  be  avoided  (the  con- 
vexity of  this  curve  of  deformity  is  usually  backward;  it  is  a 
hyperextension  of  the  leg  at  the  seat  of  fracture)  (see  Figs.  725, 
726) ;  frequent  measurements  and  inspection  of  the  leg  should  be 
made;  inspection  should  be  made  not  only  from  the  front,  but 
laterally  as  well;  readjustment  of  apparatus  is  necessitated  by 
changes  in  the  position  of  the  bones. 

The  Posterior  Wire  and  Side  Splints. — The  posterior  wire  or 
Cabot  splint  is  made  of  iron  wire  the  size  round  of  an  ordinary 
lead-pencil  (see  Fig.  727).  It  is  applied  to  the  back  of  the  foot, 
leg,  and  thigh,  extending  from  just  beyond  the  tips  of  the  toes 
to  above  the  middle  of  the  thigh.     It  is  narrow  at  the  heel  and 


Fig.  729. — The  Cabot  posterior  wire  splint  padded  completely.     Note  the  foot-pad  of  paste- 
board covered  by  cotton  cloth  pinned  to  the  foot-piece  of  the  splint  for  greater  security. 


broad  enough  above  to  permit  the  thigh  to  rest  comfortably 
upon  it.     The  foot-piece  is  at  right  angles  to  the  leg. 

Having  at  hand  the  iron  wire  the  size  of  an  ordinary  lead- 
pencil,  this  splint  can  be  quickly  and  easily  made  by  means  of  a 
vise  for  holding  the  wire,  and  a  wrench  for  grasping  the  wire  while 
bending  it.  The  two  free  ends  of  the  wire  of  the  splint  may  be 
held  firmly  together  by  having  them  overlap  and  binding  them 
together  with  small-sized  copper-wire.  These  free  ends  may,  of 
course,  be  held  by  solder. 

The  Covering  of  the  Posterior  Wire  Splint. — The  wire  is  wound 
first  with  a  roller  of  sheet  wadding,  then  with  a  cotton  roller,  and 
finally  a  cotton  roller  bandage  is  wound  about  both  sides  of  the 
splint  so  as  to  make  a  posterior  surface  upon  which  the  leg  may 
rest  (see  Figs.  727,  728,  729). 


504 


FRACTURES    OF    THE    h^G 


The  side  splints  of  wood  (see  Fig.  730)  should  be  about  tour 
inches  wide,  and  long  enough  to  extend  from  the  foot-piece  to  the 
top  of  the  splint.  The  splints  may  be  covered  with  sheet  wad- 
ding and  cotton  cloth,  as  seen  in  the  figure. 

Care  of  the  Heel. — If  but  slight  pressure  is  maintained  upon  the 
heel  even  for  a  few  days,  a  pressure  sore  will  develop.  This  is 
liable  to  increase  to  a  considerable  size.  It 
is  very  slow  in  healing.  Many  weeks  after 
the  fracture  of  the  leg  has  united  the  pres- 
sure sore  may  be  open.  It  is,  therefore,  of 
very  great  importance  to  prevent  pressure 
upon  the  heel  during  the  treatment  of  frac- 
tures of  the  lower  extremity  associated 
with  dorsal  decubitus.  There  are  four 
methods  of  avoiding  pressure  on  the  heel. 
Position  will  assist  materially.  The  posi- 
tion of  the  foot  largely  determines  the 
amount  of  pressure  falling  on  the  heel. 
When  the  foot  rests  naturally,  it  is  in  the 
position  of  slight  plantar  flexion.  The  heel 
presses  firmly  upon  the  splint  (see  Fig.  731). 
A  large  part  of  the  weight  of  the  leg  thus 
falls  upon  the  heel.  When  the  foot  is  ex- 
tended to  a  right  angle  with  the  leg,  the 
pressure  upon  the  heel  is,  in  a  large  meas- 
ure, removed  (see  Fig.  732),  Therefore,  in 
putting  up  fractures  of  the  leg  the  right- 
angle  position  is  the  desirable  one.  Padding 
above  heel  is  of  service.  The  ring  or  dough- 
nut pad  around  the  heel  is  sometimes  effi- 
cient. Slinging  the  foot  by  adhesive  straps 
applied  to  the  sides  of  the  heel  and  foot  and 
fastened  to  the  foot-piece  of  the  splint  is  a 
very  satisfactory  method  of  removing  pressure  from  the  point  of 
the  heel  (see  Fig.   733). 

The  Padding  of  the  Posterior  Wire  Splint  for  the  Reception  of 
the  Lower  Extremity. — Regard  should  be  had  for  the  natural 
curves  of  the  leg  and  thigh  posteriorly  (see  Fig.  732).    Above  the 


Fig.  730. — Side  splint  of 
splint  wood.  Method  of  pad- 
ding: (i)  Withshieet-wadding; 
(2)  with  cotton  doth;  (4)  pin- 
ned in  place,  and  then  (5) 
stitched. 


Treatment 


505 


heel,  behind  the  knee,  and  below  the  buttock  are  distinct  hollows, 
at  which  places  the  padding,  as  indicated  in  the  illustration, 
should  be  thicker  than  at  other  points.  Regard  should  likewise 
be  had  for  the  natural  lateral  curves  of  both  thigh  and  leg.  Just 
below  the  malleoli,  above  the  ankle,  below  the  knee,  and  above 
the  knee  are  distinct  hollows  that  will  require  more  padding  than 
elsewhere  on  the  sides  of  the  limb  (see  Fig.  734).  The  more  care- 
fully the  splint  is  padded,  the  more  nearly  perfect  will  be  the  re- 
sult of  treatment  and  the  greater  will  be  the  comfort  of  the  patient. 


Fig.   731. — Normal  leg  with  foot  flexed,  showing  that  the  heel  rests  heavily  on  the  table  (see 

Fig.  732). 


Fig.  732. — Posterior  outline  of  the  normal  leg,  suggesting  the  necessary  padding  to  be 
used  on  the  Cabot  splint.  When  the  foot  is  at  a  right  angle  with  the  leg,  the  heel  rests 
lightly  on  the  table. 

The  leg  is  to  be  placed  upon  the  posterior  iron  splint,  so  padded 
posteriorly  that  it  rests  naturally  and  comfortably.  The  foot 
should  be  placed  at  a  right  angle,  drawn  down  snugly  to  the  foot- 
piece,  and  steadied  by  adhesive-plaster  straps  carried  around  the 
foot  and  splint  in  a  figure-of-eight  bandage  (see  Figs.  737,  738  . 
The  side  splints,  so  padded  with  pillow-cases  or  towels  as  to  bring 
suitable  pressure  upon  the  leg  and  thigh,  are  applied  and  held  in 
position  by  straps  and  buckles  (see  Fig.  738).     This  splint  immob- 


Fig-  733- — Methods  of  supporting  the   foot  in  fractures  of  the  leg  when  using  a  posterior  splint; 
a.  Padding  beneath  tendo  Achillis;  6,  ring  under  heel;  c,  sling  of  adhesive  plaster. 

506 


TREATMENT 


507 


ilizes  the  knee  and  ankle-joints  and  the  fractured  bones.  The 
region  of  the  fracture  is  open  to  inspection  anteriorly.  Lateral 
inspection  is  facilitated  by  loosening  the  straps  and  lowering  the 
side  splints.  Any  deviation  from  the  normal  lines  of  the  leg  can 
be  adjusted  easily.     At  the  end  of  three  weeks,  when  the  fracture 


Fig.  734.— X-ray  of  fracture  in  child  of 
eight  years.  Fracture  difificult  to  hold  re- 
duced.    Bones  sutured.     Excellent  result. 


Fig.  735 — Fractures  of  the  leg.  Cabot 
posterior  wire  splint  and  side  splints,  show- 
ing the  space  to  be  padded  on  each  side  of 
the  leg  and  thigh. 


is  uniting  and  the  callus  is  still  soft,  the  leg  should  be  removed 
from  the  splint  and  examined  carefully  from  the  front,  from  the 
back,  and  laterally  for  any  deviation  from  the  normal.  If  any 
deviation  is  discovered,  it  should  be  corrected  and  the  leg  put 
again  into  a  posterior  wire  splint  or  into  a  removable  plaster-of- 
Paris  splint. 


At  the  foot. 


Suspension     At  the 
hooks.  pelvis. 


Fig.  lif'- — The  anterior  wire  suspensory  apparatus  of  N.  R.  Smith.  This  splint  is  applied 
to  the  anterior  surface  of  the  padded  foot,  leg,  thigh,  and  hip.  The  splint  is  fixed  to  the  leg 
by  a  bandage.  The  splint  is  intended  to  immobilize  the  leg  and  at  the  same  time  to  suspend 
it,  permitting  motion  at  the  hip,  and  to  secure  extension  upon  the  distal  fragments. 


Fig.   737- — Fracture  ul  llic  lug.     C.ibot  posterior  wire  splint  padded  properly  according  to  the 
curves  of  the  normal  leg.     Notice  that  the  heel  is  free  from  the  splint  (see  Fig.  732). 


Fig.  738.- 


-Fracture  of  the  leg.     Cabot  posterior  wire  splint,  side  and  posterior  wooden  splints 
held  by  straps.    Adhesive  plaster  to  foot  and  ankle. 


508 


Fig.  739. — Fracture  of  the  thigh.  Note  possibility  of  abrhuting  nr  adducting  the  limbs  below  the 
fracture.  Note  rings  incorporated  in  the  plaster  anterior  splint  for  suspension.  The  Smith  anterior 
wire  splint  may  be  arranged  in  the  same  manner  as  shown  here  for  the  plaster  anterior  splint  (Davison). 


Fig.  740.— Fracture  of  the  thigh.  Note  whole  limb  suspended  by  a  plaster-of-Paris  anterior  splint 
extending  from  instci)  to  groin  and  traction  secured  both  by  the  suspension  of  the  leg  and  the  Buck's  ex- 
tension strips  and  weight  (Davison). 


509 


5IO 


FRACTURKS    OF   THE    IvEG 


The  first  night  after  putting  up  the  fracture  the  patient  will 
probably  be  uncomfortable.  The  new  and  restrained  position, 
the  after-effect  of  the  anesthetic  if  one  has  been  used,  the  points 
of  undue  pressure  yet  to  be  adjusted,  the  itching  of  the  skin,  the 


<V 


Fig.  741. — Short-Desault  splint  for 
the  application  of  traction  to  lower  leg 
fractures.  Fracture  at  X.  Extension 
strips  up  from  the  fracture  are  fastened 
at  the  top  of  the  splints.  Extension 
strips  down  from  the  fracture  are  fast- 
ened to  the  foot-piece.  Tightening  the 
screw  at  foot-piece  makes  traction  and 
countertraction. 


Fig.  742. — Plaster  traction  splint  :  a,  Appli- 
cation of  adhesive-plaster  extension  strips  as 
in  figure  741;  3,  plaster  bandage  allowing  exit 
of  extension  straps.  Note  space  left  below  the 
sole  to  allow  for  effective  traction  and  buckles 
to  which  the  upper  extension  is  attached. 


inability  to  move  about,  the  necessity  of  lying  in  one  position, 
actual  pain  at  the  seat  of  the  fracture — all  combine  to  make  life 
miserable.  It  will  be  a  wise  precaution  on  the  part  of  the  attend- 
ant if  a  little  morphin  is  administered  subcutaneously  this  first 


TREATMENT  511 

night,  as  patient,  nurse,  and  physician  will  rest  better.  After  the 
first  night  there  will,  under  ordinary  circumstances,  be  no  especial 
difficulty.  After  the  plaster  splint  is  applied  the  Smith  anterior 
wire  splint  attached  to  the  anterior  surface  of  the  thigh,  leg,  and 
dorsum  of  the  foot  often  will  enable  the  leg  to  be  slung  just  so  as  to 
clear  the  bed.  This  position  is  one  of  considerable  comfort.  The 
patient  is  enabled  to  move  in  bed  a  little  and  to  change  his  position 
without  disturbing  the  fracture.  This  anterior  wire  splint  is  made, 
like  the  Cabot  posterior  wire  splint,  of  iron  wire,  but  is  fitted  to 
the  anterior  surface  of  the  foot,  leg,  and  thigh  (see  Fig.  736). 

Fractures  Difficult  to  Hold  Reduced. — These  are  usually  oblique 
fractures  of  the  tibia,  occurring  most  often  in  the  lower  half  of  the 


Fig.  743. — Cabot  posterior  wire  splint,  as  u^ed  lor  (>|k_u  limuues  (lateral  view).  Note 
protective  padding  of  splint  beneath  wound,  X,  to  facilitate  dressings  without  the  removal  of 
the  leg  from  the  splint. 

bone  (see  Fig.  734)-  The  nearer  to  the  ankle-joint  the  fracture  is, 
,the  greater  is  the  likelihood  of  a  displacement  which  is  hard  to 
hold  reduced.  The  contraction  of  the  quadriceps  extensor  tends 
to  pull  the  upper  fragment  forward,  the  contraction  of  the  gastroc- 
nemius tends  to  pull  the  lower  fragment  backward  and  upward. 
The  obliquity  of  the  fracture  and  the  action  of  these  two  groups  of 
powerful  muscles  make  it  almost  an  impossibility  to  hold  these 
fractures  reduced.  It  is  often,  even  under  an  anesthetic,  impos- 
sible to  correct  the  deformity  without  doing  a  tenotomy  of  the 
tendo  Achillis.  A  posterior  wire  and  side  splints  with  the  foot 
held  fixed,  with  a  moderate  traction  and  pads  placed  at  the  seat  of 
fracture,  may  be  of  service. 

A  plaster-of- Paris  splint  with  extension  and  counterextension, 


512 


Fractures  of  the  leg 


after  the  principle  of  the  Short-Desault  apparatus  and  according 
to  Lovett's  adaptation  (see  Figs.  741,  742),  will  hold  some  of  the 
more  difficult  cases. 

Method  of  Application  of  the  Traction  Plaster-of- Paris  Splint. — 
From  the  seat  of  fracture  running  upward  and  from  the  seat 


Fig.  744' — Cabot  wire  splint  in  open  fractures,  viewed  from  above.  Leg  in  position  ; 
wound  of  soft  parts  seen  ;  dressing  removed  ;  side  splints  and  straps  seen.  Upper  and  lowei 
fragments  held  by  permanent  bandages  during  inspection  of  the  wound. 


of  fracture  running  downward  are  applied  extension  adhesive 
plasters,  with  webbing  attachments,  as  seen  in  the  diagram  (see 
I^ig-  742)  Below  the  foot,  the  size  of  the  sole  of  the  foot  and  two 
inches  thick,  is  held  a  very  firm  pad  of  sheet  wadding.  A  plaster 
bandage  is  applied  to  the  leg,  according  to  the  usual  methods,  from 


TREATMENT 


513 


the  toes  to  above  the  knee.  A  buckle  looking  upward  is  incor- 
porated in  the  plaster  bandage  upon  each  side  of  the  leg  a  little 
above  the  level  of  the  knee.  A  slit  is  left  upon  each  side  of  the 
ankle  for  the  lower  extension  webbings  to  come  through  (see  Fig. 
742) .  After  the  plaster  has  hardened  the  sheet- wadding  foot-pad 
is  removed.  The  upper  extension  straps  are  pulled  snugly  over 
the  upper  edge  of  the  plaster  splint  and  fastened  to  the  buckles  on 
each  side.  Then  the  lower  straps  are  pulled  taut  over  the  foot- 
piece  of  the  plaster.     Countertraction  and  traction  are  thus  main- 


I 


Fig-  745- — Fracture  of  both  bones  of  the  leg.    Ununited  fracture  of  tibia.    Fibula  united 
(Massachusetts  General  Hospital,  1190.    X-ray  tracing). 


tained  upon  the  fragments  of  the  fracture.  A  window  is  cut  in 
the  plaster  to  observe  the  position  of  the  bones.  This  apparatus 
is  efficient  in  many  instances  in  which  it  is  otherwise  difficult  to 
maintain  reduction. 

Operative  interference  with  suture  of  the  fragments  of  bone  is 
the  most  effective  method  of  treatment  in  troublesome  cases.  It 
is  always  wise  to  delay  operating  until  after  the  primary  effects 
of  the  injury  have  ceased — that  is,  until  after  the  acute  swelling 
has  subsided  and  the  damaged  tissues  have  had  time  to  recover 
themselves.  A  delay  of  ten  days  is  time  gained.  During  these 
33 


514  FRACTURES  OF   THE    LEG 

ten  days  some  one  of  the  methods  already  mentioned  may  suc- 
ceed in  holding  the  fracture  satisfactorily  so  that  operation  is 
unnecessary. 

Treatment  of  Open  Fractures  of  the  Leg. — Treatment  rests  upon 
the  presumption  that  every  open  fracture  is  infected.  The  object 
of  treatment  is  to  convert  the  open  infected  fracture  into  a  closed 


Fig.   746. — Open  fracture  of  both  bones  of  the  right  leg  in  the  lower  third,  six  months  after  the 
accident.    Note  the  deformity  and  enlargement  of  the  leg  near  the  ankle. 

noninfected  fracture.  It  is  important  that  the  first  dressing  of 
the  wound  should  be  a  clean  one.  If  it  is  a  temporary  dressing, 
the  wound  should  be  douched  with  boiled  water,  covered  with  a 
clean  absorbent  dressing,  and  the  leg  placed  upon  a  pillow  splint. 
The  Permanent  Dressing. — Every  open  fracture  of  the  leg 
should  be  anesthetized  for  careful  examination,  diagnosis,  and  the 


TREATMENT  OF  OPEN  FRACTURES 


515 


initial  dressing.  The  leg  should  be  washed  with  soap  and  water 
and  scrubbed  with  a  gauze  sponge  or  soft  nail-brush.  The  leg 
should  be  shaved  of  all  hair  in  the  vicinity  of  the  wound,  and 
should  then  be  washed  with  liquid  sodse  chlorinatae  (chlorinated 
soda),  one  part  to  twenty.  This  will  most  effectually  free  it  from 
all  grease  and  oily  dirt. 

The  Wound  of  the  Soft  Parts.— This  should  be  moderately  en- 
larged to  allow  easy  access  to  its  deeper  parts.  There  are,  no 
doubt,  cases  of  fracture  of  the  bones  of  the  leg  open  from  within 


Fig.   747 — Lateral  view  of  figure  746.     Note  discharging  sinuses. 


outward  in  which  the  wound  is  small,  evidently  made  by  the  bone, 
in  which  it  is  prudent  to  seal  the  wound  and  to  regard  the  likeli- 
hood of  infection  as  absent.  These  cases,  chosen  in  the  judgment 
of  a  wise  surgeon,  may  do  well,  but  they  may  not ;  therefore,  the 
author  believes  it  is  safer  to  advise  that  all  wounds  of  open  frac- 
tures be  enlarged  for  thorough  cleansing.  The  blood-clot  and 
detritus  should  be  washed  out  by  irrigating  with  a  warm  solution 
of  corrosive  sublimate,  i  :  5000.  Irrigation  should  be  supple- 
mented by  thorough  scrubbing  of  the  tissues  of  the  wound  by 
small  gauze  swabs  held  in  forceps.     These  swabs  should  be  small 


5i6 


IfRACTURES    OF   THE    LEG 


enough  to  be  carried  into  all  the  recesses  of  the  wound.  All  bleed- 
ing should  be  checked.  Loose  bits  of  muscle,  fat,  fascia,  and  bone 
should  be  removed.  Often  the  finger  will  detect  bits  of  bone 
when  the  forceps  will  not.  The  firmly  attached  fragments  of 
bone  are  to  be  left  undisturbed.  Regarding  the  treatment  of  the 
slightly  fixed  fragments  of  bone,  the  surgeon  must  judge  in  each 
instance.  Is  is  a  good  rule  when  in  doubt  about  the  viability  of  a 
fragment  of  bone  to  remove  it.    The  deep  fascia  may  need  division 


Fig.  748. — Case:  Open  Pott's  fracture.     Wound  in  soft  parts  and  protruding  tibia  to  be  seen. 


to  permit  of  a  view  of  the  depths  of  the  wound.  The  fractured 
bones  are  then  to  be  approximated  and  sutured,  if  practicable. 
The  corners  of  the  wound  may  be  sutured.  It  is  wise  to  leave  the 
wound  open  enough  to  receive  several  temporary  gauze  wicks  for 
drainage  during  the  first  few  days.  Counteropenings  may  be 
needed  if  one  is  not  sure  of  the  aseptic  condition  of  the  wound. 
They  do  no  harm  and  may  prove  safety-valves  against  latent  in- 
fection. Before  leaving  the  wound  it  should  be  thoroughly 
douched  with  boiled  water.  An  aseptic  dressing  is  applied,  and 
the  leg  is  immobilized  by  the  posterior  wire  and  side  splints  (see 
Figs.  743>  744)-  or  is  put  up  immediately  in  a  plaster-of- Paris  splint. 
If  the  plaster-of- Paris  splint  is  used,  a  window  should  be  cut  in  it, 
through  which  the  wound,  if  left  unsutured  in  part,  may  be  dressed. 
Care  of  a  Fracture  of  the  Leg  after  the  Permanent  Dressing  has 
been  Applied. — All  fractures  of  the  leg  will  be  placed,  sooner  or 
later,  in  the  fixed  plaster-of- Paris  splint.     One  week  after  the 


TREATMENT  OF  OPEN  FRACTURES 


517 


splint  is  applied  the  patient  may  be  up  and  about  with  crutches. 
At  first,  the  hanging  of  the  leg  down  may  be  attended  by  great  dis- 
comfort. There  may  be  a  sense  of  fulness  and  of  burning  in  the 
leg.  The  leg  may  feel  as  if  it  would  burst.  The  toes  may  look 
blue  and  be  swollen.     Letting  the  leg  hang  down,  be  dependent. 


Fig    749.— Normal  leg  and  foot  at  a  right  angle.     Note  the  relative  position  of  heel  and  leg. 


Fig.  7S0. — Pott's  fracture.  Posterior  displacement  of  the  foot  on  the  leg.  Note  the  short- 
ening of  the  foot  from  the  toe  to  the  front  of  the  ankle.  Compare  the  relative  position  of  the 
heel  and  leg  with  the  same  in  figure  749- 


for  short  intervals  at  first,  and  alternating  with  elevating  the  leg 
until  the  uncomfortable  swelling  and  sensations  have  entirely 
disappeared,  will  enable  the  patient  to  gradually  increase  the  time 
of  lowering  the  leg  until  all  discomfort  will  have  vanished.  As 
the  patient  becomes  accustomed  to  these  conditions,  which  are  in 


5i8 


IfRACTURES   OP   THE    LEG 


themselves  harmless,  he  will  be  able  to  ignore  them;  they  will 
grow  less  and  less  troublesome,  and  eventually  disappear.  At  the 
end  of  five  weeks  the  fracture  should  be  found  very  firm.  A 
lighter  plaster  splint  may  be  then  applied,  extending  only  to  the 
knee-joint,  and  allowing  flexion  of  the  knee.  This  thin  plaster 
splint  should  be  split,  so  as  to  be  removable.  After  about  five 
weeks  from  the  injury  the  leg  should  receive  a  daily  bath  and 
massage,  with  active  and  passive  motion  to  the  knee  and  ankle- 


Fig.    7SI.— Pott's  fracture  of  left  ankle.    Method  of  examining  ankle.    Lateral  mobility  shown 
Note  the  grasp  of  the  foot  and  the  leg. 


joints.  At  about  the  eighth  week  the  protecting  sphnt  may  be 
removed,  a  flannel  bandage  from  the  toes  to  the  knee  substituted, 
and  the  patient  be  allowed  to  touch  the  foot  to  the  floor,  bearing 
a  little  weight.  Eighty-two  per  cent,  of  fractures  of  the  tibia  will 
be  solidly  united  within  seven  weeks  (Paul).  Seventy-eight  per 
cent,  of  the  fractures  of  the  tibia  and  fibula  will  be  solidly  united 
within  nine  weeks  (Paul).  Fractures  of  both  bones  of  the  leg  in 
children  under  ten  years  of  age  will  require  about  eight  weeks  for 


PROGNOSIS 


519 


solid  union.  As  soon  as  the  plaster  is  removed  and  the  bandage 
substituted,  a  shoe,  preferably  laced,  should  be  worn  on  that  foot. 
From  the  eleventh  to  the  twelfth  week  after  the  injury  the  patient 
should  be  walking  somewhat  with  a  cane.  According  to  present 
methods,  a  fractured  leg  would  require  from  three  to  five  months 
of  treatment  before  restoration  to  normal  function  is  completed. 
The  after-care  of  a  case  of  fracture  of  the  leg  is  attended  with 
no  little  anxiety  on  the  part  of  the  surgeon.  The  general  health  of 
the  patient  is  a  matter  of  considerable  concern.  The  loss  of  exer- 
cise entailed  by  the  cramped  and  unnatural  position  causes  loss  of 


Fig.   752.— Case:  Fracture  of  the  internal  and  external  malleoli  and  displacement  of  the  foot 

inward  and  backward. 

appetite,  headache,  constipation,  dyspeptic  ills,  etc.  The  pain 
through  the  whole  limb,  due  undoubtedly  to  the  sprain  and 
wrenching  at  the  time  of  the  injury,  the  aching  at  night  at  the  seat 
of  the  fracture,  combine  to  render  the  patient  thoroughly  uncom- 
fortable, unhappy,  and  even  melancholy.  Pressure  spots  will 
appear  about  the  most  carefully  appHed  bandage,  and  they  must 
receive  attention.  Itching  of  the  skin  inside  the  splints  is  some- 
times almost  unendurable.  To  every  patient  daily  general  and 
local  massage  and  bathing  will  be  found  to  be  of  unspeakable  com- 
fort. The  average  hospital  patient  is  far  less  sensitive  to  all  the 
petty  annoyances  of  an  immovable  and  closely  fitting  dressing 
than  is  the  private  patient. 

The  Prognosis.— In  children  and  young  people  the  minimum 
time  is  consumed  by  the  process  of  repair.     The  restoration  of 


520 


FRACTURES    OF   THE    LEG 


the  leg  to  its  normal  function  is  more  rapid  than  in  the  cases  of 
adults,  and  there  are  fewer  complications.  In  adults  a  chronic 
arthritis  may  appear  in  the  neighboring  knee-  or  ankle-joints. 
Swelling  of  the  leg  and  ankle  may  persist  for  some  time.  Non- 
union of  the  bones  may  result,  and  necessitate  operative  measures 
(see  Fig.  745).  If  the  fracture  is  oblique,  shortening  may  occur 
even  after  union  takes  place  if  the  unsup- 
ported leg  is  used  too  soon  and  too  much. 
If  the  wound  of  an  open  fracture  heals 
quickly,  and  there  is  little  comminution 
of  bone,  repair  will  take  place  as  in  a 
closed  fracture.  Otherwise,  an  open  frac- 
ture will  unite  more  slowly  than  a  closed 
fracture.  Persistent  swelling  of  the  leg, 
particularly  about  the  ankle,  is  associated 
with  the  convalescence  from  an  open 
fracture.  Necrosis  of  bone  at  the  seat 
of  fracture  may  occur  in  cases  of  open 
fracture  even  many  months  or  years  after 
the  original  injury.  Abscesses  and  sinuses 
may  form,  necessitating  operation  for  the 
removal  of  the  necrosed  bone  (see  Figs. 
746,  747).  For  some  unknown  reason 
fractures  of  the  upper  third  of  the  tibia 
unite  less  readily  than  fractures  of  bone 
elsewhere.  Union  is  longer  in  being  con- 
summated. If  the  fracture  is  near  the 
knee,  or  ankle-joints,  the  prognosis  is  more 
uncertain  than  if  the  fracture  is  at  the 
center  of  the  shaft.  A  comminuted  frac- 
ture is  more  likely  to  be  longer  in  uniting 
and  to  give  rise  to  trouble  after  repair  than  is  a  single  transverse 
fracture. 

Results  after  Fractures  of  the  Leg. — Of  value  in  this  connec- 
tion are  the  results  following  fracture  cf  the  leg  in  thirty-five  cases 
treated  at  the  Massachusetts  General  Hospital,  and  examined  one 
and  a  half  to  ten  years  after  the  accident.  In  the  detailed  report 
of  these  cases  the  exact  lesion  and  its  seat  will  be  stated.  In 
thirteen  cases — in  ten  of  which  the  age  was  fortv-two,  the  rest 


Fig.  753. — Same  as  figure  752. 
Lateral  displacement  of  foot  in- 
ward (see  X-ray  tracing,  Fig.  756). 


pott's  fracture;  521 

under  thirty — the  result  reported  was  that  the  injured  leg  was  "  as 
good  as  the  other  leg."  In  twenty-two  cases  the  result  was  a  leg 
permanently  impaired  in  some  particular.  Some  cases  had  flat- 
foot,  deformity  of  the  leg,  limited  motion  at  the  knee-joint,  lame- 
ness, necrosis  of  bone,  pain  in  the  fracture  when  the  weather  was 
damp.  Other  cases  had  pain  in  the  leg  upon  standing,  stiffness  of 
the  ankle,  pain  upon  stepping  on  uneven  surfaces,  weakness  of  the 
leg,  swelling  of  the  leg  and  foot,  cramps  at  night  in  the  calf  of  the 
leg,  or  some  combination  of  these  symptoms. 

Thrombosis  and  Embolism. — Thrombosis  of  the  veins  about  a 
fracture,  and  particularly  about  a  fracture  in  which  there  is  some 
laceration  of  the  soft  parts,  is  not  at  all  uncommon.  At  times, 
and  rather  more  frequently  than  is  generally  supposed,  emboli  are 
detached  from  these  thrombi  and  cause  almost  immediate  death, 
with  symptoms  of  pulmonary  embolism — namely,  a  sudden  cyano- 
sis and  great  difficulty  in  breathing  associated  with  intense  pre- 
cordial distress. 

Thrombosis  of  the  veins  of  the  leg  or  thigh  is  undoubtedly  one 
of  the  causes  of  the  great  edema  seen  after  fracture  of  these  parts. 

Refracture  of  the  Bones  of  the  Lower  Extremity.^— It  is  not  an  un- 
common experience  to  find  that  a  patient  with  a  fracture  of  the 
thigh,  leg,  or  patella  refractures  the  partially  united  bone.  This 
refracture  is  due  to  either  muscular  violence  or  a  slight  fall.  There 
is  ordinarily  little  displacement  of  the  fragments.  The  callus  of 
the  original  injury  holds  the  bones  quite  securely.  The  leg  is 
usually  bent  at  the  seat  of  the  fracture.  Refracture  is,  therefore, 
practically  a  fracture  of  callus.  This  accident  has  even  occurred 
while  the  patient  is  wearing  a  protective  splint  of  plaster-of- Paris. 
Union  in  these  cases  is  much  more  rapid  than  after  the  original 
injury.  About  one-half  the  time  required  for  union  of  the  original 
fracture  is  necessary  for  union  of  the  refracture.  The  patient 
may,  therefore,  be  much  encouraged,  for  though  the  accident  of 
refracture  is  a  disheartening  one,  yet  he  will  not  be  obliged  to  look 
forward  to  a  long  confinement. 


POTT'S  FRACTURE 
Anatomy. — The  anatomical  relations  of  the  lower  ends  of  the 
fibula  and  tibia  and  the  astragalus  and  os  calcis  should  be  kept 


522 


FRACTURES    OF    THE    LEG 


constantly  in  mind.  The  os  calcis  and  astragalus  are  held  firmly 
together,  forming  the  posterior  portion  of  the  foot.  The  astrag- 
alus rests  mortise-like  between  the  internal  and  external  malleoli 
(see  Fig.  758).     The  strength  of  the  inferior  tibiofibular  articula- 


Fig. 


-A  posterior  displacement  of  the  whole  foot  because  of  a  Pott's  fracture. 


Pig_  ^j5_ — \  lateral  displacement  of  the  foot  to  the  outer  side  because  of  a  Pott's  fracture.  Note 
prominent  internal  malleolus  and  swelling  of  the  ankle.  The  normal  bony  landmarks  are  not  seen. 
The  pathological  bony  landmark  is  evident. 

tion  depends  upon  the  strong  inferior  tibiofibular  ligaments,  par- 
ticularly upon  the  interosseous  ligament. 

By  Pott's  fracture  of  the  ankle  is  understood  the  injury  caused 
by  forcible  eversion  and  abduction  of  the  foot  upon  the  leg.  The 
lesions  which  may  be  present  in  this  fracture  are  a  rupture  of  the 
internal  lateral  ligament,  a  fracture  of  the  tip  of  the  internal 
malleolus,  a  separation  of  the  lower  tibiofibular  articulation,  an 


pott's  fracture 


523 


oblique  fracture  of  the  fibula  two  or  three  inches  above  the  tip  of 
the  external  malleolus,  a  fracture  of  the  outer  edge  of  the  lower  end 
of  the  tibia.  Ordinarily,  the  mechanism  of  the  fracture  is  some- 
what as  follows:  As  the  foot  is  abducted,  the  strain  is  felt  at  the 
internal  lateral  hgament  and  at  the  inferior  tibiofibular  interos- 
seous hgament,  and  these  give  way.  If  the  force  continues,  the 
fibula  breaks.  If  the  force  still  continues,  the  internal  malleolus 
is  pushed  through  the  skin,  and  an  open  fracture  results  (see 
Fig.  748).  If  the  internal  lateral  ligament  holds  against  this 
lateral  force,  the  tip  of  the  internal  malleolus  may  be  pulled 
off. 


\ 


Internal  malleolus. _  -Z/_  f, 

Astragalus. 


Scaphoid. 


I  Internal  malleoli. 


Pig.  756.— Fracture  of  both  malleoli  (anteroposterior  view).  Inversion  of  foot  (X-ray  tracing). 

Symptoms.— The  ankle  presents  a  very  constant  appearance 
after  this  fracture.  A  traumatic  synovitis  exists.  Great  swelling 
appears,  at  first  chiefly  upon  the  inner  side  of  the  ankle.  The 
ankle-joint  becomes  distended  with  blood  and  serum.  All  the 
natural  hollows  about  the  joint  are  obliterated.  The  foot  is 
everted,  appearing  to  have  been  pushed  bodily  outward.  The 
internal  malleolus  is  unduly  prominent.  Some  of  this  prominence 
is  masked  by  the  swelling.  The  bony  connections  and  natural 
support  of  the  foot  having  been  removed,  the  foot  drops  bacK- 


524 


FRACTURES    OF   THE)    LEG 


ward,  partly  because  of  the  pull  of  the  calf -muscles,  but  chiefly 
because  of  its  own  weight  (see  Figs.  749,  750).     The  deformity, 


Astragalus. 


Fig.  757 — Fracture  of  the  tip  of  each  malleolus.    Dislocation  of  the  foot  backward.    Note  the 
prominence  in  front  of  the  ankle.     Same  case  as  figure  756  (X-ray  tracing). 


Diaphysis  of  fibula. 


Epiphysis. . 


Diaphysis  of  tibia. 


—  Epiphysis. 
Astragalus. 


Fig.  758. — Normal  ankle-joint,  showing  epiphyses  (anteroposterior  view). 


therefore,  is  a  double  one,  a  lateral  sliding  of  the  foot  outward  and 
an  anteroposterior  dropping  of  the  foot  backward.     The  malleoli 


upper  end  of  lower  frag- 
ment of  fibula. 


Astragalus.  — 


L  Tibia. 


—  T '  Internal  malleolus. 


Fig-  759- — ^Pott's  fracture    (anteroposterior  view).      Note  sliding  of    astragalus    outward. 
Fracture  of  internal  malleolus.     Fracture  of  fibula.     Extreme  deformity  (X-ray  tracing). 


,  Lower  fragment  ot 

fibula. 


1  Fibula. 

,  Tibia. 


Fig.   v6o. — Pott's  fracture.    Same  as  figure  759  (lateral  view). 


s^s 


526 


FRACTURES    OF   THE    LEG 


are    spread    apart:  the  measured    distance  between   them  is  in 
creased  over   the  normal.      Palpation  close   above    the   anterior 
articular  edge  of  the  tibia  and  the  astragalus  reveals  tenderness 
over  the  ruptured  tibiofibular  ligament.     The  backward  displace- 


OS  CALCIS 


ASTRAa^UlS 


Fig.  761. — Fracture  of  the  internal  malleolus  and  of  the  lower  end  of  the  fibula.  Arrows  point  to 
lines  of  fracture.  May  be  well  reduced  without  operation.  Important  to  correct  backward  displace- 
ment of  the  foot. 


ment  is  best  measured  by  the  length  of  the  line  from  the  front  of 
the  ankle  to  the  cleft  between  the  first  and  second  toes.  This  line 
will  be  found  shortened  upon  the  injured  side.  There  is  tender- 
ness over  the  fracture  of  the  fibula.  If  the  internal  malleolus  is 
fractured,  the  sharp  ridge  at  the  broken  edge  can  be  distinctly 


TREATMENT  OF  POTT's  FRACTURE 


527 


felt.  Grasping  the  posterior  part  of  the  foot  firmly  with  the  whole 
hand  while  the  other  hand  steadies  the  lower  leg  just  above  the 
ankle,  abnormal  lateral  mobility  of  the  foot  may  be  detected  (see 
F'ig-  751).  The  foot  will  be  felt  to  move  inward  to  its  natural  posi- 
tion. The  moment  inward  pressure  is  removed  the  foot  will  be 
seen  and  felt  to  slump  outward  again. 

Figures  752-757  inclusive  illustrate  a  reversed  Pott's  deformity ^ 


Fracture  of  fibula. 


Astragalus. 


—  Unusual  space, 
[^ Internal  malleolus. 


Fig.  762.— Pott's  fracture.     Notice  sliding  of  astragalus  outward.     Fractures  of  internal  mal- 
leolus and  fibula  (Massachusetts  General  Hospital,  631.     X-ray  tracing). 

the  foot  having  moved  inward  instead  of  outward  as  well  as  having 
fallen  backward. 

Treatment. — The  indications  for  treatment  are  to  place  the 
parts  in  their  normal  relations,  and  to  maintain  them  so  until 
repair  is  completed,  guarding  against  both  the  lateral  and  the  pos- 
terior deformities.  If  for  any  reason,  such  as  the  presence  of  very 
great  swelling  of  the  ankle,  it  is  expedient  to  delay  reduction,  the 
leg  should  be  placed  temporarily  in  a  pillow  and  side  splints  (see 
Figs.  722,  723,  724).  An  anesthetic  should  always  be  adminis- 
tered before  the  reduction  of  this  fracture.  The  reduction  is  thus 
rendered  painless  and,  through  relaxation  of  the  muscles,  is  made 
far  easier.  The  principles  of  the  old  Dupuytren  splint  are  the  ones 
to  be  applied  in  the  reduction  of  this  fracture  whatever  the  appa- 
ratus in  which  the  leg  is  permanently  placed.  These  consist  of 
the  making  of  lateral  outward  pressure  upon  the  internal  malleo- 
lus, lateral  inward  pressure  upon  the  foot,  and  a  forward  lift  upon 
the  posterior  part  of  the  foot  or  heel.    The  practitioner  may  very 


r* 

m 

Fig.  763. — Note  rotation  c£  foot  on  Fig.  764. — Note  sliding  of  foot        Fig.  765. — Separation  o5 

anteroposterior  axis.  to  outer  side.  lower  epiphysis  of  tibia  and 

fracture  of  fibula. 


Fig.  766. — Note  sliding  of  foot  without  rotation. 


Fig.  767. — Note  extreme  displacement. 


Fig.  768. — Great  displacement  of  the  foot.     Note  Fig.  769. — Note  displaced  malleoli, 

prominent  internal  malleolus. 
Figs.  763-769. — Types  of  fracture  near  the  ankle-joint.     Pott's  fracture  (M.  G.  H.  series). 

528 


TREATMENT  OF  POTT's  FRACTURE  529 

properly  use  the  Dupuytren  splint.  It  is  thought  to  be  uncom- 
fortable, but  it  is  not  if  properly  applied.  It  is  very  efficient  in 
holding  the  fracture  reduced. 

The  Dupuytren  Splint. — This  is  a  board  from  one-quarter  to 
one-half  of  an  inch  thick,  long  enough  to  extend  from  the  middle 
of  the  thigh  to  six  inches  below  the  sole  of  the  foot,  and  as  wide  as 
the  calf  of  the  leg  from  front  to  back  (see  Fig.  770).  At  its  lower 
or  foot  end  it  is  serrated  with  three  or  four  teeth,  as  seen  in  the 
illustration.  It  is  padded  with  folded  sheets,  so  that  when  it  is 
applied  to  the  inner  surface  of  the  limb,  the  padding  extends  to 
just  above  the  level  of  the  internal  malleolus,  the  serrated  end  of 
the  splint  projecting  six  inches  below  the  sole  of  the  foot.  The 
padding,  as  seen  in  the  illustration,  is  so  thick  at  the  lower  end  over 
the  internal  malleolus  that  sufficient  room  is  left  for  inversion  and 
rotation  of  the  foot  upon  its  anteroposterior  axis  without  its  im- 
pinging upon  the  splint  in  the  least.  The  splint  is  held  in  place  by 
straps  and  buckles:  one  is  placed  above  the  ankle,  one  above  the 
knee,  and  a  third  is  placed  at  the  upper  end  of  the  splint.  For  the 
proper  application  of  the  splint  an  assistant  is  needed.  The  splint 
is  applied  while  the  leg  rests  upon  the  bed.  An  assistant  steadies 
the  splint  and  the  leg  so  that  they  both  project  clear  of  the  foot  of 
the  bed.  A  roller  bandage  is  then  applied  in  circular  turns  about 
the  ankle  and  splint  from  the  splint  toward  the  leg.  After  two 
circular  turns  are  made,  the  assistant  adducts  and  inverts  the 
ankle  and  foot,  and  this  position  is  held  by  the  third  turn  of  the 
bandage,  which  is  passed  around  the  forward  part  of  the  foot  and 
over  one  of  the  serrations  of  the  splint  (see  Fig.  77 1)-  In  order 
to  hold  this  firmly  a  turn  is  then  taken  around  the  ankle.  A 
figure  of  eight  is  then  applied  for  several  turns  about  the  foot  and 
ankle,  crossing  the  ankle  in  front  of  the  instep  at  each  turn.  Each 
succeeding  turn  is  caught  by  the  succeeding  serration  of  the  splint. 
At  the  same  time  the  foot  is  lifted  forward  by  pressure  from  be- 
hind, and  this  forward  lift  is  maintained  by  circular  turns  of  the 
bandage.  The  whole  limb  is  placed  upon  pillows.  Thus,  the 
eversion  and  posterior  dropping  of  the  foot  are  corrected.  This 
splint  forms  a  good  temporary  or  emergency  dressing  for  Pott's 
fracture.  This  dressing  corrects  the  eversion,  but  there  is  great 
34 


530 


FRACTURES    OF   THE    LEG 


danger  that  the  foot  may  slump  backward  unless  most  carefully 
watched.  This  failure  to  hold  the  posterior  displacement  cor- 
rected is  the  defect  of  the  Dupuytren  splint. 

The  Posterior  Wire  Splint  with  Curved  Foot-piece  (see  Figs.  772, 
773)  774)- — The  posterior  wire  splint  extending  to  the  middle  of 
the  thigh  is  another  apparatus  used  in  treating  Pott's  fracture. 


tig- 77° — Pott's  fracture.     Dupuytren's  splint.     Note  length  of  splint;  position  of  straps; 
arrangement  of  padding  ;  space  between  foot  and  splint. 


The  foot-piece  should  be  twisted  at  the  ankle,  so  as  to  hold  the 
foot  when  inverted  (see  Fig. -772).  The  splint  is  covered  and 
padded  in  the  usual  way.  The  patient  is  anesthetized.  The 
leg  is  placed  upon  the  splint.  The  foot  is  strongly  inverted  by 
great  lateral  pressure  put  upon  the  posterior  part  of  the  foot.  This 
inversion  of  the  foot  can  not  be  made  too  strongly,  for  the  deform- 


TREATMENT  OI^  POTT'S  FRACTURE 


531 


ity  can  not  be  overcorrected.  The  position  of  extreme  inversion 
is  not  a  painful  one  to  maintain.  Ordinarily,  the  lateral  pressure 
applied  is  too  slight  entirely  to  correct  the  deformity.  The  foot  is 
held  to  the  inverted  foot-piece  by  straps  0/  adhesive  plaster,  pads, 
and  side  splints  (see  Fig.  773).     A  pad  is  applied  to  the  sole  of  the 


Fig.  77i> — Pott's  fracture.  Dupuytren's  splint. 
Note  serrations  of  splint  and  turns  of  bandage 
adducting  foot. 


Fig.  772. — Cabot  posterior  wire 
splint  bent  at  the  ankle  for  a  Pott's 
fracture  of  the  right  leg.  To  be  used 
to  assist  in  maintaining  adduction  of 
the  foot. 


foot,  and  so  placed  as  to  maintain  the  long  anteroposterior  arch 
of  the  foot.  It  is  found  that  if  this  is  not  done,  there  is  consider- 
able flattening  of  this  arch  upon  recovery.  The  forward  lift  upon 
the  foot  is  made  and  maintained  by  proper  padding  posteriorly  to 
the  lower  leg  and  just  above  the  heel  (see  Fig.  772)-  The  lift  may 
be  reinforced  by  smoothly  applied  strips  of  adhesive  plaster  placed 


532 


FRACTURES    OF    THE)    LEG 


laterally  on  the  foot  and  carried  under  the  heel  and  up  and  over 
the  end  of  the  foot-piece.  These  adhesive-plaster  strips  serve  as  a 
sling  for  the  foot.  There  is  one  other  way  to  avoid  pressure  upon 
the  point  of  the  heel,  and  that  is  by  placing  beneath  the  heel  a  rin£f 

of  sheet  wadding  covered  with  a  tightly 
wound  bandage  (see  Fig.  735).  These 
methods  of  protecting  the  heel  from 
pressure  may  all  be  used  at  one  time 
to  advantage.  The  side  splints  are 
applied  with  great  care,  being  so  padded 
as  to  maintain  the  outward  pressure 
upon  the  inner  surface  of  the  lower  end 
of  the  tibia,  and  the  inward  pressure 
upon  the  outer  surface  of  the  foot.  Very 
great  care  must  be  exercised  that  there 
is  no  recurrence  of  the  deformity. 
Frequent  readjustments  are  necessary. 
Tlie  Lateral  and  Posterior  Plaster- 
of -Paris  Splints  (Stimson's  Splint). — 
The  posterior  splint  (see  Fig.  774)  ex- 
tends from  the  toes  along  the  sole  of 
the  foot  around  the  back  of  the  heel 
and  up  the  back  of  the  leg  to  the  knee 
or  to  the  middle  of  the  thigh.  The 
lateral  sphnt  (see  Fig.  775)  begins  at 
the  external  malleolus,  passes  over  the 
dorsum  of  the  foot  to  the  inner  side 
Fig.   773-  — Pott's   fracture,    under  the   solc,   and  upward   along  the 

Cabot  posterior    wire    splint   and  .,  ,-,11  j^i  i-ii 

side  splints.    Note  position  of  lat-    outcr  Side  of  the  leg  to  the  samc  height 

eral  pads  and  twisted  foot-piece,  g^g  ^^^  poStCrior  SpHut.  Each  of  theSC 
Side  splints  are  shown  unpadded 

(diagram).  spHuts   is   made   of   about   six   or   eight 

strips  of  washed  crinoline,  four  inches 
wide  and  long  enough  to  extend  from  around  the  foot  to  the 
bend  of  the  knee  or  middle  of  the  thigh.  The  leg  is  pro- 
tected by  roller  bandages  of  sheet  wadding.  Plaster  cream 
is  rubbed  into  the  crinoline  strips  one  after  the  other  until  all 
the  strips  have  been  used.  The  posterior  splint  is  appUed  first, 
and  held  snugly  by  a  gauze  bandage  to  the  leg  and  foot.  Then 
the  remaining  crinoline  strips  are  likewise  covered  with  plaster 


TREATMENT  OF  POTT  S  FRACTURE 


533 


cream  and  applied  as  the  lateral  splint  (see  Fig.  776).  This 
is  also  held  snugly  by  a  gauze  bandage  to  the  leg  and  foot.  Dur- 
ing the  application  of  the  splint  and  until  the  plaster-of-Paris 
has  set,  the  foot  should  be  held  in  a  corrected  position  by  an  as- 
sistant. These  two  plaster-of-Paris  splints  are  preferable  to  the 
encircling  plaster  splint,  the  ordinary  "plaster  leg,"  for  by  their 
use  the  ankle  can  be  inspected.  Less  judgment  is  requisite  in  its 
application  to  insure  the  correction  of  the  deformity  than  by  the 


Fig.  774. — Pott's  fracture.     Stimson's  splint.     Posterior  plaster  (represented  two  inches  too 
long  at  the  upper  end). 


use  of  the  ordinary  "plaster  splint."  As  the  swelling  subsides 
and  the  plaster  becomes  loose,  if  the  splints  are  kept  tight  by 
bandaging,  the  deformity  can  not  possibly  recur. 

Care  0}  the  Fracture  after  the  Permanent  Dressing  is  Applied. — 
If  the  posterior  and  side  splints  are  used :  After  the  initial  swelling 
has  subsided — i.  e.,  after  the  first  week — the  leg  may  be  placed  in  a 
plaster-of-Paris  splint  (circular  bandage),  and  the  patient  allowed 


534  FRACTURES   OF   THE    LEG 

up  and  about  with  crutches.  The  plaster  should  be  split  after 
application  and  held  in  place  by  straps  or  a  bandage.  If  the 
Stimson  splint  is  used,  the  patient  may  be  allowed  up  and  about 
with  crutches  at  the  end  of  the  first  week. 

Massage  may  be  applied  to  the  exposed  parts  of  the  leg  and  foot 
daily.     At  the  third  week  all  dressings  should  be  removed,  and 


Fig.  775- — Pott's  fracture.    Stimson's  splint  completed.    Lateral  plaster  and  posterior  plaster. 

gentle  massage  applied  to  the  whole  leg  from  toes  to  groin,  especial 
attention  being  paid  to  the  region  of  the  ankle.  Massage  and 
gentle  passive  motion  in  an  anteroposterior  direction  only  should 
be  applied  at  least  once  or  twice  daily  after  the  second  week.  All 
lateral  motion  is  to  be  avoided.  After  the  fifth  or  sixth  week  a 
flannel  bandage  will  be  all  the  support  needed,  although  comfort 


Treatment  of  pott's  fracture 


535 


may  demand  a  thin,  stiff,  retentive  splint  at  times.  At  the  end 
of  two  months  some  weight  may  be  borne  upon  the  foot. 

Of  the  three  methods  of  dressing  a  Pott's  fracture  the  posterior 
and  lateral  plaster  splint  of  Stimson  is  by  far  the  simplest  and  it  is 
efficient  in  every  way.  Moreover,  it  allows  of  massage  being  in- 
stituted early  with  the  least  disturbance  to  the  ankle.  The  pos- 
terior wire  splint  is  more  difficult  of  application,  and  needs  careful 
watching  and  frequent  readjustment.  With  the  posterior  wire 
splint  in  use  the  foot  or  leg  is  easily  accessible  to  early  massage  by 
simply  loosening  the  side  splints. 

Prognosis  and  Results. — In  young  adults  there  should  be  no 


Fig.  776. — Pott's  fracture.     Stimson's  splint  removed.     Lateral  and  posterior  plasters. 


deformity  and  almost  no  permanent  disability.  In  adults  there 
will  be  some  stiffness  for  a  time.  //  the  lateral  deformity  has  not 
been  completely  corrected,  a  traumatic  pronation  of  the  foot  will 
result.  The  longitudinal  arch  of  the  foot  should  be  supported 
always  by  a  suitable  pad  under  the  instep  for  at  least  six  months 
following  this  fracture,  whether  there  is  deformity  or  not.  If 
there  is  deformity,  it  will  relieve  the  pain.  An  insole  of  leather 
with  a  pad  stitched  to  it  for  support  to  the  arch  of  the  foot  is  often 
of  great  service.  If  there  is  no  pain  or  deformity,  it  will  strengthen 
the  foot  until  walking  is  easy  again,  and  will  prevent  deformity 
appearing.  //  the  anteroposterior  deformity  has  not  been  cor- 
rected, pain  may  be  experienced  upon  using  the  foot.    The  foot  is 


536 


FRACTURES   OF   THE    LEG 


shortened  and  dorsal  flexion  is  much  hindered,  so  that  the  gait  is 
decidedly  impaired.  The  patient  will  walk  with  a  more  or  less 
stiff  ankle.  In  those  cases  in  which  there  is  great  deformity 
associated  with  extensive  laceration  of  the  soft  parts,  the  foot  and 
ankle  may  for  many  weeks  subsequent  to  union  be  painful,  stiff, 
and  swollen.  Pain,  stiffness,  and  swelling  increase  with  the  age 
of  the  patient — i.  e.,  the  younger  the  patient,  the  less  discom- 
fort will  there  be  following  this  fracture. 


Fig-  7V7. — Old  fracture  of  tibia  and  fibula  with 
compensatory  and  actual  deformity  (Feiss). 


Fig.  7-8.- 


-Old    fracture  of    ankle    with   actual 
deformity  (Feiss). 


Open  Pott's  Fracture  (see  Fig.  748). — The  ankle-joint  is  in- 
volved. Two  things  are  to  be  considered  in  deciding  upon  the 
treatment  of  the  injury — the  extent  of  the  laceration  of  the  soft 
parts  and  the  amount  of  injury  to  the  bones.  If  the  laceration  is 
so  great  that  the  foot  is  useless,  amputation  is  indicated.  Am- 
putation is  indicated  in  only  two  other  instances — old  age  and 
sepsis.  If  the  laceration  is  not  great,  and  any  existing  disloca- 
tion can  be  reduced,  it  should  be  reduced  without  excision,  proper 
drainage  being  provided,  both  anteriorly  and  posteriorly,  to  the 


TREATMENT  OF  POTT'S  FRACTURE 


537 


joint.  If  the  laceration  is  not  great  and  reduction  of  the  deform- 
ity is  impossible,  then  either  partial  or  complete  excision  should 
be  done.  If  there  is  great  injury  to  bone,  whether  the  disloca- 
tion can  or  can  not  be  reduced,  a  partial  or  complete  excision 
should  be  done.  In  every  open  Pott's  fracture,  no  matter  how- 
small  the  wound  of  the  soft  parts,  in  order  to  insure  an  aseptic 


Fig.    779. — Xray  of  actual  bony  condition  before  operation   (Feiss). 

wound  it  should  be  enlarged  sufficiently  for  thorough  cleansing 
with  antiseptic  solutions  in  every  part.  Extreme  conservatism 
should  characterize  the  treatment  of  recent  open  Pott's  fracture. 
In  the  large  majority  of  cases  treated  upon  the  conservative  or 
expectant  plan  a  useful  ankle-joint  and  foot  will  result.  The 
older  the  adult  patient  is,  the  more  radical  must  be  the  treat- 
ment. 


538 


FRACTURES   OF   THE   LEG 


The   Operative  Treatment   of  Old  Pott's  Fractures.— The 

exact  indications  for  operation  in  old  deforming  Pott's  fracture 
will  be  persisting  lateral  or  backward  displacements.  The  only 
method  for  the  relief  of  these  deformities  is  by  osteotomy  of  the 


Fig.  780. — Diagram  showing  operative  lines  of  osteotomy  to  correct  old  deformity  (Feiss). 


tibia  and  fibula.     The  results  following  this  operation  are  satis- 
factory. 

The  Operative  Treatment  of  Old  Fractures  of  the  Leg  Near 
the  Ankle. — The  indications  for  treatment  of  old  deforming 
fracture,  whether  following  fracture  of  the  lower  epiphysis  of  the 
tibia,  Pott's  fracture,  or  fracture  of  the  tibia  and  fibula  just  above 


TREATMENT  OF  POTT'S  FRACTURE 


539 


the  ankle,  are  the  same— the  reestabhshing  the  proper  weight- 
bearing  line.  It  is  important  to  eliminate  from  the  problem  the 
compexisatory  functional  deformity. 

The  following  case  (Feiss)  is  cited  to  illustrate  the  method  of 
procedure  applicable  to  many  of  these  cases. 


Fig.   781. — Casts  showing  appearance  of  ankle  before  and  after  operation(Feiss). 

Fig.  777  shows  the  position  of  the  ankle  and  foot  due  to  damage 
to  the  epiphysis  of  the  lower  end  of  the  tibia.  Fig.  778  shows  the 
real  deformity  upon  putting  the  foot  in  a  position  of  rest.  Fig. 
779  shows  the  X-ray  illustrating  the  abnormal  growth  of  the  bones. 

By  an  osteotomy  of  the  tibia  and  resection  of  a  piece  from  the 
fibula,  as  planned  in  Fig.  780,  it  was  possible  to  correct  the  static 
deformity,  with  the  result  seen  in  Fig.  781. 


Fig.  7S2.— Fracture  of  the  lower  epiphysis  of 
the  tibia  close  to  shaft,  and  of  the  lower  fibular 
epiphysis  with  displacement  of  the  foot  inward. 


Fig.  7SJ. — Fracture  of  the  lower  tibial 
epiphysis  extending  up  into  tlie  inner  edge  of 
the  diaphysis  of  the  tibia.  A  starting  of  the 
lower  fibular  epiphysis. 


Fig.  784. — Fracture  of  the  lower  tibial  epiphysis  and  damage  to  the  epiphysis  further  outward. 


540 


Fig.  785. — A  fracture  of  the  lower  tibial  epiph-         Fig.  786. — A  fracture  of  the  lower  tibial  epiph- 
ysis with  displacement  slightly  upward.  ysis    a    little  within  the  longitudinal  line  of  the 

diaphysis  of  the  tibia. 


Fig.  7JS7.     A  slnrting  of  (lu:  lower  tibial  cpiiiliysis.     Nolc  the  iiurcaseii  spacing  in  the  epiphyseal  line. 


Fig.  788. — Lateral  and  anteroposterior  views.  Note  oblique  fracture  from  before  backward  of 
epiphysis  at  its  inner  side  and  starting  of  the  epiphysis  of  the  fibula,  also  a  starting  of  the  lower  tibial 
epiphysis. 


Fig.  789.— Fracture  of  the  outer  portion  of  the  inferior  tibial  epiphysis.     Note  also  change  in  outline  of 
the  anterior  portion  of  epiphyseal  line  indicated  by  the  arrow. 


CHAPTER  XV 

FRACTURES  OF  THE  BONES  OF  THE  FOOT 

Fracture  of  the  astragalus  is  caused  by  a  blow  on  the  sole  of 
the  foot,  as  in  a  fall  from  a  height  (see  Fig.  79°) •  Fracture  of  the 
OS  calcis  is  often  present  in  the  same  foot  with  fracture  of  the 
astragalus.  The  ankle-joint  may  or  may  not  be  involved.  The 
diagnosis  is  difficult  without  the  use  of  the  Rontgen  ray.  Crepitus 
may  be  elicited.  Great  swehing  may  appear  in  the  region  of  the 
fracture. 


Tibia. 


Line  of  fracture 


H«ad  and  neck  "y 

of  astragalus.  /    \ 

Cuneiform.     Scaphoid.    \  ^ 


External 

1  '      malleolus. 

Body  of  astrag- 
alus. 


—  Os  calcis. 


—  Cuboid. 


Fig.  790. — Fracture  of  the  neck  of  the  astragalus  (X-ray  tracing). 


It  is  highly  probable  that  many  cases  of  sprained  ankle  have 
been  cases  of  fracture  of  the  astragalus.  If  there  is  no  displace- 
ment, treatment  wih  consist  in  immobilizing  the  ankle-joint  with 
the  foot  held  at  a  right  angle  with  the  leg.  As  soon  as  the  swelling 
has  begun  to  subside,  massage  may  be  used  to  advantage  and  con- 
valescence be  thus  hastened.  The  most  satisfactory  dressing  is  a 
plaster-of- Paris  splint  extending  from  the  toes  to  below  the  knee, 
applied  and  immediately  split  open,  so  as  to  form  a  removable 
splint.     This  may  be  taken  off  for  massage  and  passive  motion. 

543 


Cuneiform 


Cuboid 


Astragalus 


Os  calcis 


Fig.  791. — Dorsal  view  of  bones  of  the  foot.     Tarsus,  metatarsus,  and  phalanges. 


Cuneiform  Scaphoid 


Os 
calcis 


Fig.  702. — ^Latera!  viev/  of  foot  showingr  longitudinal  arch  of  foot.     Note  relation  of  indi- 
vidual bones  on  inner  side  of  foot. 


544 


FRACTURE    OF    THE    OS    CALCIS 


545 


Recovery  takes  place  with  fair  movement  at  the  ankle-joint,  so 
that  after  from  two  months  and  a  half  to  three  months  the  patient 
can  walk  without  support.  After  this  time  complete  recovery  is 
slow.  More  or  less  stiffness  and  pain  may  exist  for  four  or  six 
months  after  the  accident. 

Fracture  of  the  Os  Calais. — The  os  calcis  is  fractured  by  a 
fall  on  the  sole  of  the  foot,  as  well  as  by  a  powerful  contraction  of 


Fibula 


Tibia 


Fibula 


Astragalus 


Scaphoid 


Cuneifomj 


Cuboid 


Fig.   793,— An  X-ray  of  the  bones  of  the  normal  adult  ankle  and  part  of  tarsus.     Lateral 

view. 


the  gastrocnemius  muscle  and  strong  tension  upon  the  tendo 
Achillis.  It  may  be  crushed,  fractured  transversely  or  longi- 
tudinally, or  a  piece  may  be  torn  off  from  its  posterior  portion 
near  the  insertion  of  the  tendo  Achillis  (see  Fig.  802).  The 
symptoms  of  fracture  will  be  the  usual  ones  of  crepitus,  swell- 
ing, pain,  and  abnormal  mobility.  The  heel  is  seen,  by  compari- 
son with  its  uninjured  fellow,  to  be  enlarged.  This  fracture  is 
sometimes  associated  with  fracture  of  the  astragalus  (see  Fig. 

35 


Fig.  794. — Fracture  of  the  astragalus.  Patient  fell  ten  feet  to  ground,  September,  1900.  "  Sprained 
ankle."     X-ray,  fracture  of  neck  of  right  astragalus. 

March,  1901.     Bad  result.     Useless   foot.      Partial   ankylosis.     Partial   astragalectomy,  Brooks. 

May,  1905.  Foot  slightly  inverted,  longitudinal  arch  raised,  no  lateral  motion,  no  fle.xion,  10 
degrees  of  extension.     Painful  foot.     Bad  result   (Cabot,  Binney). 


Fig.  795  — Fracture  of  astragalus.  Fracture  due  to  direct  violence,  from  heavy  bar  falling  on 
foot.     May,  1904.     Plaster-of-Paris  bandage. 

July  4.     Trendelenburg  osteotomy. 

May,  1905.  Painful  foot.  Forward  displacement  of  foot  on  leg.  E.xaggerated  longitudinal 
arch.  Deformity  not  wholly  corrected  by  operation.  Marked  inversion.  Flexion  good.  Extension 
limited.     Lateral  motions  limited.     Bad  result  (Cabot,  Binney). 


Fig.  796. — Fracture  of  astragalus.  Foot  run  over  by  heavy  team,  February,  1902.  Treated 
by  natural  bone  setter.     X-ray  shows  fracture  of  neck  of  astragalus.      Operation  advised  and  refused. 

September,  1905.  Painful  foot.  Much  inversion,  large  bony  fragment  on  dorsum  (head  of 
astragalus).  Flexion  fair.  Extension  poor.  No  lateral  motion.  Foot  very  flat.  Bad  result  (Cabot, 
Binney). 

546 


fracture;  of  the  os  calcis — treatment 


547 


Fig.  797' — Fracture  of  astragalus.     X-ray  shows  impaction  of  astragalus,  especially  in  central  portion, 
with  lowering  of  ankle-joint  (Cabot,  Binney). 


Fig.  798. — Fracture  of  the  os  calcis.  Man,  40  years,  fell  ten  feet,  striking  squarely  upon  both 
heels,  on  the  ground. 

X-ray  shows  fracture  of  the  os  calcis  of  the  large  heel  fragment  type. 

This  is  a  favorable  case  for  tenotomy  of  the  tendo  Achillis  and  reduction  of  the  posterior  frag- 
ment, with  restoration  of  the  arch  (Cabot,  Binney). 


Fig.  799. — Fracture  of  the  os  calcis.  This  patient,  a  man,  fell  15  feet  on  to  frozen  ground,  striking 
upon  both  feet,  in  February,  1899.  Right  heel  showed  abnormal  mobility  and  crepitus  over  the  os 
calcis.  X-ray  shows  comminuted  fracture  with  large  heel  fragment.  Treated  with  pillow  splint ; 
plaster-of-Paris  bandage. 

May,  1895.  Has  some  pain  through  ankle-joint.  Always  wears  an  insole.  Is  considerably 
hindered  about  his  work.  Examination,  right  foot  :  Considerable  bony  overgrowth  beneath  external 
malleolus.  Motions  :  No  flexion  beyond  right  angle.  No  adduction.  Very  little  abduction.  Fair 
extension.     Good  position.     Longitudinal  arch,  fair.     Classed  as  fair  result  (Cabot,  Binney). 

806).  The  treatment  is  to  immobilize  the  foot  at  the  angle  that 
will  best  hold  the  fragments  approximately  in  apposition.  Com- 
plete plantar  flexion  of  the  foot  may  be  needed  to  bring  the  frag- 


Fig.  800. — Fracture  of  the  os  calcis.  Man,  26,  fell  from  moving  car,  striking  left  foot  against 
tie.  In  May,  1899,  X-ray  shows  fracture  of  os  calcis,  large  heel  fragment  type,  with  tendency  of  pos- 
terior fragment  to  be  drawn  upward.     Plaster -of-Paris  bandage. 

June,  1905. — Reports  returned  to  work  after  three  and  a  half  months.  \'ery  little  trouble  at 
any  time.  Foot  becomes  tired  after  long  day's  work.  Present  condition,  slight  fulness  beneath  ex- 
ternal malleolus.  Extension  good.  Flexion  slightly  limited.  Wry  little  lateral  motion.  No  "flat 
foot."     Classified  as  good  result  (Cabot,  Binney). 


Fig.  801. — Fracture  of  the  os  calcis.     Shows  same  foot  as  Fig.  800,  six  years  after  injury.     Note  great 
thickening  of  central  portion  of  os  calcis  with  fusion  of  astragalo-calcaneal  joint  (Cabot,  Binney). 


Fig.  802 — Fracture  of  the  os  calcis.  A  good  example  of  small  heel  fragment  type  of  fracture. 
Caused  by  slipping  while  getting  on  a  street  car,  apparently  by  sudden  contraction  of  calf  muscles. 
Operation  refused.     Result  unknown  (Cabot,  Binney). 

548 


fracture;  of  the  OS  CALCIS — TREATMENT 


549 


ments  well  into  position.      The  pull  upon  the  tendo  Achillis  is  in 
this  position  removed  from  the  posterior  fragment.     If  the  frag- 


Fig.  S03. — Fracture  of  the  os  calcis.  Shows  another  type  of  comminuted  fractiu'e  of  the  an- 
terior half  of  the  os  calcis.  Note  great  flattening  of  longitudinal  arch.  Result  unknown  (Cabot, 
Binney). 


Fig.  S04. — Fracture  of  the  os  calcis  (right)  (Cabot, Binney). 


Fig.  80s. — Fracture  of  os  calcis  (left). 


ments  cannot  be  reduced,  exposure  of  them  may  be  wise  by  in- 
rision.  I'vxcision  of  certain  portions  or  retention  of  fragments 
by  a  nail  or  screw  or  plate  may  be  helpful.     Massage  should  be 


550 


FRACTURES    OF    THE)    BONES    OF  THE    FOOT 


instituted  early — during  the  first  week.  The  removable  plaster- 
of-Paris  dressing  is  the  best  form  of  splint.  After  three  weeks 
the  splint  should  be  removed,  and  a  close-fitting  flannel  bandage 
applied,  with  small  pads  under  the  malleoli  and  on  each  side  of 
the  tendo  Achillis.  The  pads,  if  applied  with  considerable  pres- 
sure, will  assist  very  materially  in  reducing  the  swelling  and  in 
restoring  form  to  the  ankle.  It  will  be  about  two  months  before 
the  patient  should  bear  much  weight  upon  the  foot.  After  three 
to  four  months  walking  will  be  comparatively  easy. 

It  is  often  the  case  after  fracture  of  the  os  calcis  and  also  after 
fracture  of  the  astragalus,  in  which  complete  reduction  has  not  been 
secured,  that    there   is   considerable   disturbance  of   the   normal 


Fig.  806. — Case  :  Posterior  view  of  fracture  of  right  os  calcis  and  of  left  astragalus.      Deformity. 
Note  fulness  each  side  of  the  tendo  Achillis  (see  X-ray  tracing  7Qo)- 


mechanism  of  the  foot.  A  traumatic  flat-foot  results  from  the 
accident.  This  can  be  greatly  relieved  by  the  introduction  into 
the  shoe  of  a  leather  pad,  to  raise  the  instep  and  take  the  strain  off 
the  injured  part.  The  patient  may  find  that  for  a  period  of  six 
months  or  more  the  wearing  of  this  pad  is  a  great  support  and 
comfort.  If  the  use  of  a  flat-foot  support  does  not  relieve  these 
old  cases  an  osteotomy  must  be  considered  as  helping  to  secure  a 
restoration  of  the  arch.  The  hot-air  baking  is  very  satisfactory 
for  the  relief  of  the  pain  and  stiffness  felt  throughout  the  ankle 
and  foot.  The  hot-air  treatment,  combined  with  massage,  helps 
to  hasten  convalescence.  This  treatment  should  be  used  once 
daily  until  the  pain  in  the  foot  has  disappeared. 


FRACTURE    OF   THE   METATARSAL    BONES 


551 


If  there  is  a  dislocation  of  a  portion  of  the  astragalus,  either  the 
fragment  must  be  accurately  reduced  or,  if  this  is  impossible,  the 
fragment  should  be  removed. 

If  there  is  a  compound  fracture  of  the  astragalus,  and  the  time 
elapsed  since  the  injury  is  several  hours,  it  will  be  unwise  to  as- 
sume that  the  wound  can  be  completely  cleansed.  Excision  of  the 
fragment  or  of  the  entire  astragalus  will  be  the  most  conservative 
treatment.  At  the  same  time  thorough  posterior  drainage  should 
be  provided  by  a  rubber  tube  for  the  cavity  left  after  excision. 

Open  fracture  of  the  astragalus  and  os  calcis,  if  treated  anti- 
septically,  recovers  with  a  useful  ankle  and  foot  even  though  the 
ankle-joint  is  ankylosed.     The  mediotarsal  joint  becomes  more 


Seat  of  fracture. 


Sesamoid  bones. 


Fig.  807. — Fracture  across  the  first  metatarsal  of  the  right  foot  (X-ray  tracing). 


flexible  than  it  ordinarily  is.  The  loss  of  motion  at  the  ankle- 
joint  is  compensated  for  by  the  mediotarsal  joint  motion,  and  the 
individual  may  walk  with  hardly  a  perceptible  limp.  Removal 
by  operation  of  the  fractured  bone  is  attended  by  good  functional 
results,  and  if  the  bone  is  much  comminuted  or  dislocated,  opera- 
tion is  indicated.  A  careful  study  of  the  results  of  fracture  of  the 
astragalus  and  of  the  os  calcis,  as  published  by  Cabot  and  Binney 
and  recorded  here  in  X-rays  (Figs.  794-805),  will  prove  very  helpful. 
Fracture  of  the  Scaphoid  of  the  Tarsus.  Fracture  of  the 
Metatarsal  Bones. — This  fracture  is  caused  by  direct  violence. 
There  is  evidence  to  show  that  indirect  violence  may  cause  a 
fracture  of  metatarsal  bones.  The  first  and  fifth  bones  are  the 
ones  most  often  broken  (see  Fig.  807) .    The  symptoms  are  swelling, 


552 


FRACTURES    OF   THE    BONES    OF   THE    FOOT 


pain,  crepitus,  and  abnormal  mobility.  The  weight  can  not  be 
borne  upon  the  foot  without  pain.  There  is  never  great  displace- 
ment. In  order  to  avoid  trouble  in  walking,  after  union  has  oc- 
curred it  is  wise  to  make  the  approximation  of  the  fragments  as 


Fig.  80S. —  Fracture  of  the  sesamoid  bone  of  the  metatarsophalangeal  joint  of  the  left  foot.  An 
unusual  injury,  but  to  be  reckoned  with  when  persistent  pain  after  an  injury  in  this  region  is  present 
(C.  Painter.) 


Fig.  809.— Transverse  fracture  of  the  fifth  metatarsal  bone. 


nearly  accurate  as  possible.  A  closed  or  simple  fracture  is  ordi- 
narily uncomplicated.  Union  takes  place  in  from  three  to  four 
weeks.  It  will  be  at  least  from  two  to  four  months  before  the  foot 
can  be  used  without  thought  of  the  injury  received. 


FRACTURE   OF   THE    PHALANGES  553 

If  the  fracture  is  open,  repair  will  be  slower  than  after  a  closed 
fracture.  If  the  wound  is  kept  clean  and  free  from  infection,  no 
complications  will  arise.  If,  on  the  other  hand,  the  wound  be- 
comes infected,  necrosis  of  bone,  abscess  formation,  burrowing  of 
pus,  and  great  swelling  of  the  foot  may  occur,  all  of  which  will 
greatly  delay  the  healing  process.  The  foot  should  be  immobilized 
by  a  lateral  molded  splint  of  plaster-of- Paris.  This  should  be 
placed  upon  either  the  outer  or  inner  side  of  the  ankle,  according 
as  the  outer  or  inner  metatarsals  are  broken.  The  splint  should 
extend  from  the  middle  of  the  calf  of  the  leg  to  the  tips  of  the  toes. 
It  is  held  in  position  by  a  roller  bandage  of  gauze. 

Fracture  of  the  Phalanges  of  the  Foot. — These  fractures  are 
rather  unusual,  except  from  a  crush  of  the  foot.  They  are 
sometimes  open.  The  same  general  rules  of  treatment  apply 
to  fractures  of  these  bones  as  to  fractures  of  the  phalanges  of 
the  hand.  A  simple  plantar  splint  of  splint  wood,  padding  of 
the  toes,  and  adhesive-plaster  straps  will  be  sufficient  to  hold  the 
fracture.  If  the  plantar  splint  covers  the  entire  sole  of  the  foot,  it 
will  prove  of  great  comfort.  It  is  sometimes  wise  to  immobilize 
the  ankle-joint  by  the  thin  plaster  side  splint,  particularly  if  there 
is  swelling  of  the  leg  and  ankle. 


CHAPTER  XVI 

THE  OPERATIVE  TREATMENT  OF  FRACTURES 

It  is  an  opportune  time  to  state  explicitly  a  conservative  and 
progressive  view  of  the  question  of  the  operative  treatment  of 
fractures  of  bone. 

It  should  be  possible  for  the  surgeon  often  to  select  those  frac- 
tures in  the  initial  treatment  of  which  operative  measures  will 
afford  better  results  than  non-operative  methods. 

It  is  evident  that  with  increasing  experience  in  both  methods  of 
treatment  the  surgeon   will   transfer  certain  fractures  from   the 


Fig.  8io. — Fracture  of  the  shaft  of  humerus  in  upper  third.     Often  impossible  to  reduce  without  opera- 
tive assistance. 


operative  list  to  the  non-operative  list  and  vice  versa.  There  will 
always  be  a  varying  group  of  debatable  cases,  upon  the  treatment  of 
which  class  of  cases  there  will  be  honest  differences  of  opinion. 
No  surgeon  advocating  the  operative  treatment  for  most  fractures 
will  be  thought  wholly  just.  Neither  would  a  surgeon  advocating 
the  non-operative  treatment  for  most  fractures  be  thought  wise 
in  the  light  of  recent  results. 

It  is,  of  course,  necessary  for  practitioners  of  surgery  to  assume 

554 


THE  OPERATIVE  TREATMENT  OF  FRACTURES 


555 


that  there  is  general  agreement  that  operation  is  ordinarily  wise 
upon  ununited  fractures  and  upon  fractures  which  have  united  with 
distressing  deformity  and  with  much  impairment  of  function. 

Deficiencies  in  non-operative  treatment,  which  unquestionably 
do  exist,  should  be  remedied,  not  by  operating  more  frequently, 
but  by  exercising  greater  care  iii  the  employment  of  the  fundamen- 
tal principles  recognized  the  world  over  as  underlying  the  non- 
operative  treatment  of  all  fractures,  namely,  general  anesthesia; 
traction,  countertraction;  pressure,  counterpressure;  the  exact 
application  of  anatomic  knowledge ;  immobilization ;  the  compara- 
tive use  of  the  Rontgen  ray;  massage;  the  care  of  joints  adjacent 


Fig.  8ii. — Fracture  of  the  surgical  neck  of 
the  humerus  with  disphicement  of  both  frag- 
ments. Reduced  most  intelligently  if  assisted 
by  an  incision. 


Fig.  812. — Iracture  of  the  shaft  of  the  hu- 
merus in  lower  third.  Approximation  most 
accurately  secured  through  operation. 


to  the  injury,  and  thus  ultimately  securing  approximately  ana- 
tomic form  and  perfect  function.  Whenever  and  wherever  these 
basic  principles  are  applied  intelligently  and  consistently,  the 
results  are  uniformly  good  and  the  operative  margin  is  narrow. 

Every  surgeon  believes  in  the  operative  treatment  of  certain 
recent  fractures,  provided  the  indications  for  operation  are  clear. 
Operating  on  freshly  fractured  bone  is  safe  to-day  if  the  operative 
technic  is  perfect.  Osteitis  and  necrosis  do  not  commonly 
follow  properly  placed,  direct  fixative  materials.  Union  of  the 
fracture  is  usually  facilitated  and  not  delayed  by  operation. 
Damage  to  the  soft  parts  extensive  enough  to  cause  postoperative 


556 


THE  OPERATIVE  TREATMENT  OF  FRACTURES 


difficulties  may  be  avoided  and  is  not  a  menace.  The  local  con- 
ditions surrounding  recent  fractures  are  quite  different  from  those 
discovered  at  the  seat  of  an  old  fracture.  It  is  far  easier  to  operate 
upon  a  recent  fracture  than  upon  an  old  fracture. 


Fig.  813. — Fracture  at  epiphyseal  line  of 
lower  end  of  humerus.  Reduction  may  be  ^•ery 
much  facilitated  by  an  incision  and  direct  digi- 
tal pressure  on  fragment  of  epiphysis. 


Fig.  814. — Fracture  at  epiphyseal  line  of  lower 
end  of  the  humerus. 


Fig.  S15. — Fracture  of  both  bones  of  the 
forearm,  with  union  of  the  radius  and  non- 
union of  the  ulnar.  Operation  indicated  to 
secure  union  in  good  position. 


fig.  816. — Fracture  of  the  upper  third  of  the 
shaft  of  the  femur. 


Anatomic  results  are  ideal  and  theoretically  desirable.  Prac- 
tically they  are  often  unessential.  The  ideal  treatment  may 
not  be  most  expedient.  Operation  is  often  contraindicated 
chiefly  because  it  is  unnecessary.  It  must  be  remembered  that 
the  results  of  operative  treatment  may  not  be  more  satisfactory 


the;  operative  treatment  of  fractures 


557 


than  are  the  results  from  non-operative  treatment.  Operation 
does  not  carry  with  it  the  guarantee  of  a  perfect  anatomic  result. 
The  majority  of  simple  or  closed  fractures  can  be  satisfactorily 
treated  by  non-operative  methods. 

The  broad  indications  for  operation,  in  my  opinion,  on  recent 
closed  fractures,  in  the  absence  of  great  damage  to  soft  parts,  in- 
cluding vessels  and  nerves,  is  the  inability  to  bring  fragments  into 
such  apposition  and  alignment  that  good  functional  results  will 
follow  in  a  reasonable  time. 


Fig.  817  —Oblique  fracture  of  the  lower  third  of  the  femur. 


Fig.  818. — Fracture  of  the  shaft  of  the  femur  above  the  condyles. 

Each  individual  case  should  be  judged  upon  its  own  merits  in 
order  to  determine  whether  or  not  it  should  be  operated  upon. 
The  exact  local  conditions  of  the  fracture  should  be  thoroughly 
understood  from  a  careful  study  of  X-rays  taken  in  different 
planes.  The  bone  broken,  the  exact  situation  in  the  bone  of  the 
fracture,  and  the  character  of  the  fracture,  all  these  facts  must  be 
carefully  determined.  The  general  condition  of  the  patient  should 
be  carefully  considered  just  as  before  instituting  any  surgical  pro- 
cedure.    The  resisting  powers  of  the  patient  should  be  taken  into 


558 


THE  OPERATIVE  TREATMENT  OF  FRACTURES 


account.  The  patient's  position  and  duties  in  life  deserve  atten- 
tion. 

Among  the  following  fractures  of  the  long  bones  will  be  found 
those  most  frequently  offering  clear  indications  for  operative 
treatment: 

Separation  of  the  upper  epiphysis  of  the  humerus.  The  assist- 
ance sometimes  afforded  by  an  incision  and  direct  digital  replace- 
ment associated  with  manipulation  is  undoubted. 

Fracture  of  the  surgical  neck  of  the  humerus  with  retraction  of 
the  fascia,  causing  reduction  to  be  impossible  without  an  anesthetic 
and  at  times  an  incision. 


Fig.  819. — Oblique  fricture  of  the  tibia. 


Fig.  S20. — Fracture  of  botli  bones  of  the  lea 


Separation  of  the  lower  epiphysis  of  the  humerus  may  require 
an  incision  in  order  to  facilitate  direct  digital  reduction. 

Fracture  of  the  radius  or  ulna  alone  with  displacement  may  be 
most  effectually  treated  by  an  incision  and  a  plate. 

Fracture  of  both  bones  of  the  forearm,  in  order  to  increase  the 
chances  of  securing  pronation,and  supination,  will  require  internal 
splinting. 

Fracture  of  the  upper  third  of  the  femur,  oblique  fracture  of 
the  shaft  of  the  femur,  fracture  of  the  lower  third  of  the  femur, 
fracture  of  the  tibia  and  the  fibula  in  the  lower  third,  very  rarely, 
fracture  of  the  clavicle,  separation  of  the  lower  epiphysis  of  the 


the;  operative  treatment  of  fractures 


559 


femur,   J-fractures   into   the  knee-joint— all  these  may   require 
operative  measures. 

The  Hst  might  be  lengthened.  In  all  these  fractures  mentioned 
above  cases  are  continually  coming  under  observation  in  which 
convalescence  might  be  shortened,  functional  usefulness  might  be 
very  materially  increased,  and  evident  deformity  eliminated  by  an 
open  incision  and  direct  fixation. 


Fig.  821. — A  simple  drill  for  bone. 

Operation  upon  recent  fractures  of  bone  may  mean  simply  an 
incision  to  assist  in  the  reduction  of  the  displaced  fragment. 
Operation  does  not  necessarily  mean  the  introduction  of  any 
foreign  body,  be  it  suture,  screw,  staple,  or  plate.  Too  often  it  is 
presupposed  that  by  operation  is  meant  the  use  of  some  internal 
fixative  apparatus.  The  displaced  part,  once  assisted  to  reduction 
by  an  incision,  will  often  remain  reduced  without  further  help, 
becoming  locked  together. 

Fractures  entering  joint  surfaces    call  for   careful    attention. 


56o 


THE  OPERATIVE  TREATMENT  OF  FRACTURES 


Variations  from  the  normal  anatomical  relations  will  be  most  likely 
to  cause  functional  disability  when  the  fracture  involves  joint 
surfaces.  Hence  careful  attempts  at  perfect  reduction  must  be 
made.  In  general  it  may  be  stated  that  if  pretty  accurate  re- 
duction of  joint  fractures  is  impossible  by  non-operative  treatment, 
then  operative  measures  should  be  employed. 

The  Method  of  Operating  Upon  the  Shafts  of  the  Long  Bones. 
— The   field    of   operation   should  be  scrupulously   clean.     Only 


Fig.  822. — Lowman's  clamp  for  holding  the  shaft  of  bone.     Note  bone  plate  in  situ. 


sterile  instruments  should  come  into  contact  with  the  soft  parts 
and  the  bone.  A  minimum  of  trauma  should  be  used  upon  the 
tissues  through  the  employment  of  an  ample  incision  of  the  soft 
parts.  The  bone  should  be  displaced  as  little  as  possible  from  its 
normal  bed.  The  material  to  be  used  for  direct  fixation  may  be 
very  occasionally  chromic  catgut,  or  a  steel  pin,  or  a  bit  of  alumi- 
num bronze  wire,  or  a  screw  or  a  staple.  Most  frequently  a  steel 
plate  held  in  place  by  at  least  two  screws  on  either  side  of  the  frac- 


OPERATING  UPON  THE  SHAFTS  OF  THE  LONG  BONES    56 1 

ture  will  be  the  best  method  of  fixation.  The  plates  and  screws 
employed  by  Mr.  Arbuthnot  Lane  are  most  satisfactory.  The 
staples  made  in  San  Francisco  are  useful  (Huntington). 

Immobilization  of  the  part  after  being  operated  upon  may  be 
secured  most  effectively  by  the  use  of  plaster-of- Paris  splints.  It 
is  always  safe  to  immobilize  the  part  operated  upon  with  great  care 
and  attention  to  the  exact  position  of  the  fragments.     All  that  is 


Fig.  823. — Martin's  bone  clamp  for  holding  bone  fragments  in  alignment. 


gained  by  operation  may  be  lost  by  a  careless  slip  or  oversight  of 
this  plan. 

Some  method  of  permanent  traction  is  necessary  while  operating 
upon  a  recent  fracture  of  the  femoral  shaft,  in  order  to  secure  the 
proper  length  of  the  limbs.  The  method  employed  by  Hunting- 
ton and  illustrated  in  Fig.  594  is  efficacious  and  simple.  The 
traction  is  applied  to  groin  and  ankle  by  skeins  of  worsted  or 
yarn.  This  traction  is  maintained  during  the  operation,  and  until 
plates  or  other  fixative  appliance  has  been  placed  securely. 

During  the  past  three  years  it  has  been  demonstrated  that  the 
36 


562 


The  operative  treatment  of  fractures 


operative  treatment  of  fractures  of  the  shafts  of  the  bone  as  well 
as  the  fractures  entering  the  joints  is  a  safe  procedure.  The 
results  following  the  operative  treatment  of  fresh  fractures  are 
encouraging,  in  many  cases  brilliant. 

Martin's  employment  of  direct   traction  upon  the  end  of  the 
distal    fragment  by   means   of  strong  canvas   strips  and  heavy 


Fig.  824. — Lane's  steel  plates  for  use  in  fractures  of  bone. 


weight  (fifty  pounds)  is  a  distinct  contribution  to  the  operative 
treatment  of  fractures  of  the  shaft  of  the  femur. 

It  must  ever  be  kept  in  mind  that  a  very  definite  indication  for 
operation  must  be  present  before  any  individual  case  is  submitted 
to  the  additional  risk  of  incision  and  direct  fixation. 


OPERATING  UPON  THE  SHAFTS  OF  THE  LONG  BONES    563 

What  should  be  the  attitude  of  the  general  practitioner  toward 
fractures  which  may  require  skilled  surgical  treatment?  The  X- 
ray  is  not  available.  The  surgeon  cannot  be  had  upon  summons. 
The  physician  should  state  the  facts  to  the  patient  in  the  presence 
of  another  physician  so  as  to  explain  the  situation.  He  should 
state  definitely  that  an  X-ray  is  needed  to  ensure  greater  accuracy 
in  treatment  and  consequently  a  better  result.  He  should  advise 
positively  and  leave  the  matter  to  the  adult  patient  to  decide.  It 
may  evidently  be  necessary  upon  occasion  for  the  physician  to 
insist  upon  the  patient  being  carried  to  an  X-ray  in  an  adjoining 
town,  where  skilled  interpretation  of  the  X-ray  plate  may  be  had 
and  treatment  indicated  by  the  findings  instituted. 

The  physician  should  not  assume  the  responsibility  of  the  care 
of  a  fracture  of  the  bone  without  stating  to  the  patient  or  friends 
the  value  to  be  had  from  an  X-ray  and  skilled  advice.  It  is  pos- 
sible to-day  to  secure  both  the  X-ray  and  the  skilled  advice  at 
nominal  cost,  if  necessary.  There  is,  therefore,  no  reasonable 
excuse  for  ordinarily  omitting  these  two  important  adjuncts  in  the 
treatment  of  fractures  of  bone. 


CHAPTER   XVII 

PATHOLOGICAL    FRACTURES 

These  fractures  are  due  to  local  alterations  in  the  strength  of 
the  bone  occasioned  by  (i)  a  new  growth;  (2)  an  infectious  or 
inflammatory  process;  (3)  changes  in  the  bone  associated  with 
a  general  disease.  The  brittleness  of  the  bone  (osteopsathyrosis) 
is  increased  by  (i),  (2),  or  (3).  The  fracture  is  symptomatic  of 
the  general  or  local  disturbance.  Trauma,  even  though  it  be 
slight,  is  necessary  to  cause  the  break;  hence  the  term  "spon- 
taneous fracture  "  is  improperly  applied. 


Fig.  825. — Benign  cyst  of  femur.     Pathologic  fracture  because  of  this  benign  cyst.     Operation;  cyst 
cleared  away.     Good  bony  union  later  (Balch). 

A.  "Symptomatic  Fragilifas  Ossium." — (i)  Local  changes  in 
the  bone  may  be  due  to  primary  sarcoma.  Metastatic  sarcoma 
is  rarely  found  in  bone.  Metastatic  hy pernephromata  may  be  the 
occasion  of  a  fracture  of  one  of  the  long  bones,  usually  the  femur 
or  humerus.  The  pathologic  fracture  may  be  the  first  evidence  of 
the  sarcoma  or  the  hypernephroma.  There  is  rarely  union  fol- 
lowing this  fracture.     Myeloma  may  occasion  a  fracture  of  bone. 

Metastatic  Carcinoma. — -Primary  carcinoma  of  the  breast 
yields  the  largest  number  of  metastatic  carcinomatous  fractures. 
The  femur  is  the  common  site  of  the  fracture.    Union  almost  never 

564 


METASTATIC    CARCINOMA 


565 


takes  place  after  fracture  associated  with  metastatic  carcinoma. 
Benign  bone  cysts  are  not  uncommonly  the  seat  of  fracture.  The 
femur  is  the  common  seat  of  these  fractures  (see  Fig.  825).  A  trivial 
injury  in  a  healthy  young  adult  followed  by  a  fracture  which  is 
comparatively  painless  and  is  followed  by  non-union  after  a 
reasonable  period  of  immobilization  is  strongly  suggestive  of  a 


Fig.   826. — Osteomyelitis,  fracture  of  radius 
(PainterJ. 


Fig.  827. — Osteomyelitis  (Painter). 


fracture  through  a  cyst  of  the  bone.  Operation  upon  the  cyst, 
thoroughly  removing  it,  leaving  intact  all  healthy  appearing  bone 
and  again  immobilizing  it  by  suture  if  needed  and  by  apparatus 
will  often  secure  a  firm  union.  Repair  is,  however,  often  delayed — 
possiblv  because  of  incomplete  removal  of  the  cyst  wall. 

(2)   Local  changes  in  the  bone  may  be  due  to  inflammatory 
processes. — Infectious  osteomyelitis  sometimes,  though  rarely,  gives 


566 


PATHOLOGICAL    FRACTURES 


rise  to  fracture.  I  record  here  one  instance  of  this  condition  in 
a  case  of  Painter  (see  Figs.  826,  827,  828).  A  girl  two  years  old 
had  a  trivial  fall  and  injured  the  right  radius.  The  bone  was 
broken.     The  injury  was  treated  as  if  it  were  an  ordinary  fracture. 


Fig.  828. — Osteomyelitis  (Painter). 


Fig.  829. — A  case  of  osteomalacia  (Painter). 
Note  supracondylar  (fractures)  deformities  of  the 
femora  and  similar  deformity  of  forearm  (see  X- 
ray). 


No  union  resulted.  A  tender  swelling  soon  after  appeared  within 
a  centimeter  of  the  tip  of  the  radial  styloid  and  spontaneously 
opened,  discharging  pus.  An  X-ray  disclosed  an  osteomyelitic 
focus.  Several  operations  were  done  for  the  removal  of  this 
focus  and  eventually  the  bones  were  united  by  suture. 

In  such  cases  of  osteomyelitis,  the  osteomyelitic  focus  should 
be  treated  upon   general  surgical  principles   (thorough  drainage 


TUBERCULAR    OSTEOMYELITIS — OSTEOMALACIA 


567 


and  the  employment  of  the  endosteum  and  periosteum  in  the 
reparative  process)  and  subsequently  the  resulting  impairment 
of  the  bone  cared  for. 

Tubercular    osteomyelitis    may  allow    of    a    fracture,   but    the 
sequence  is  a  rare  one  (see  Fig.  836). 


Fig.  830. — X-ray  of  osteomalacia  case  of   Painter.      Note  multiple  fractures  of  radius  and  of  the 
humerus  (see  Fig.  829). 


Syphilis  very  rarely  occasions  fracture. 

Tabes  Dorsalis. — Fracture  may  occur  in  any  stage  of  the 
disease.  It  may  be  the  first  sign  of  the  disease.  The  fracture 
is  most  often  in  the  lower  extremity.  Pain  is  often  absent, 
consequently  the  fracture  is  overlooked.  These  fractures  heal 
rather  slowly,  union  is  delayed,  an  excess  of  callus  is  formed. 

Syringomyelia  is  accompanied  by  fracture  of  bone  most  often 
in  the  upper  extremity. 

(3)  Osteomalacia  is  accompani:;d  by  fracture.    The  X-rays  (Fig. 


568 


PATHOLOGICAL    FRACTURES 


830,  Fig.  831)  and  the  photograph  (Fig.  829)  illustrate  well  the 
appearances  in  this  disease.  These  are  illustrations  of  the  case 
of  Painter.  The  cystic  appearances  and  destruction  of  the  cor- 
tex and  medulla  of  the  bone  in  this  disease  are  well  illustrated. 
The  seat  of  fracture  through  these  rarefied  areas  of  the  bone  and 
the  excessive  amounts  of    callus  developed  at  the  site  of    the 


T 


Fig.  831. — X-ray  of  Painter's  case  of  osteomalacia.     Note  fracture  of  femur.     Arrow  points  to  seat 
of  fracture  (see  Fig.  829). 

fracture  are  also  well  shown.     Rachitis  is  accompanied  by  frac- 
ture (see  Fig.  834), 

B.  "Idiopathic  Fragilitas  Ossium." — Osteogenesis  imperfecta 
(see  Fig.  838)  (periosteal  dysplasia)  is  a  term  applied  to  the 
brittleness  of  bones  associated  with  multiple  fracture  of  the  bone 
in  intra-uterine  life — a  congenital  condition.  The  etiology  is 
unknown.  The  number  of  fractures  is  variable.  Union  is  rapid. 
The  characteristic^  of  the  X-ray  are  the  feeble  shadow,  the  thin 
and  atrophic  bone,  the  medullary  cavity  increased  at  the  expense 


Fig.  832.— Upper  end  of  the  femur  in  osteomalt 


cia  in  a  woman  60  years  old. 


Fig.  833. — Coxa  vara  following  fracture  of  fem- 
oral neck. 


Fig.  834. — Spontaneous  fracture  near  epiphysis 
of  femur  (rachitis). 


Fig.  835.— Separation  of  epiphysis  in  coxa  vara.         Fig.  836.— Tuberculosis.    Separation  of  epiphys 


570 


PATHOLOGICAL    FRACTURES 


Fig.  837. — Fragilitas  ossium.  A  frac- 
ture which  has  occurred  in  the  lower  end 
of  a  femur,  possibly  the  seat  of  fragilitas 
ossium. 


Fig.  8,38. — Osteogenesis  imperfecta    (Dodd    and   Os- 
good). 


of  the  cortex,  the  epiphyseal  Hnes  sharply  defined,  and  the  pres- 
ence of  very  evident  fractures. 

Prognosis. — Simmons  writes:  "The  prognosis  is,  on  the  whole, 
rather  imfavorable.  The  mortality  in  the  first  few  months  of  life 
is  extremely  high,  but  in  the  milder  cases  there  has  been  a  distinct 
tendency  as  the  child  reaches  puberty  for  the  bones  to  become 
more  normal,  and  the  liability  of  fracture  to  cease,  although  in 
other  cases  the  fractures  have  occurred  with  increasing  frequency. 
In  those  cases  where  the  condition  has  occurred  in  adults,  there 
may  be  a  spontaneous  cure,  or  the  disease  may  progress  from  bad 
to  worse.     Ultimate  deformity  is  almost  sure  to  occur." 


CHAPTER   XVIII- 
ANATOMICAL  FACTS  REGARDING  THE  EPIPHYSES 

Hitherto  our  knowledge  of  injuries  to  the  epiphyses  has  been 
obtained  mainly  through  clinical  and  pathological  observation. 
This  knowledge  is  only  approximately  correct.  With  the  assist- 
ance of  the  Rontgen  ray  a  very  great  advance  is  being  made  in  the 
accuracy  of  our  knowledge  of  the  epiphyses.  Whereas  there  will, 
perhaps,  always  exist  differences  in  the  times  of  the  appearance  of 
the  ossification  centers  and  the  times  of  union  of  the  epiphyses,  the 
discrepancies  in  each  observer's  series  of  cases  will  grow  less  and 
less. 

The  importance  of  an  exact  knowledge  of  the  epiphyses  to  those 
having  to  do  with  injuries  in  the  neighborhood  of  joints  is  un- 
doubted. The  diagnosis,  prognosis,  and  treatment  of  joint  in- 
juries and  injuries  in  the  immediate  vicinity  of  joints  is  far  more 
satisfactory  than  ever  before.  The  book  by  John  Poland  upon 
"Traumatic  Separation  of  the  Epiphyses,"  from  which  the  follow- 
ing data  are  largely  taken,  marks  an  era  in  this  branch  of  surgery. 
Only  those  facts  that  are  considered  especially  important  for 
practical  everyday  use  are  here  mentioned. 

THE   DATE   OF   THE   APPEARANCE   OF   OSSIFICATION  IN  THE 
CHIEF  EPIPHYSES  OF  THE  LONG  BONES 

{After  Poland) 

.  ^  1  .  ^1  f  Lower  end  of  femur. 

At  birth ^  fT  ,     f  ..,  . 

(  Upper  end  ot  tibia. 


umerus. 


.  ^  .  (  Upper  end  of  femur 

At  one  year <  tt  j     r  i, 

•'  [  Upper  end  oi  nume 

.^  7  1,  If  (  Lower  end  of  tibia 

At  one  and  one-halt  years <  ,  i     r  i 

^  I  Lower  end  of  hum 


merus. 


.  ^  ^  r  Lower  end  of  radius. 

At  two  years {  ^  i     r  cu  i 

•'  (^  Lower  end  ot  nbula. 

.      ,  J  Great  troclianter  of  femur. 

At  three  years |  ^^^^j.  f^,^g,.Q,ity  ^f  humerus. 

.  .  r  f  Upper  end  of  uhia. 

At  four  years <  tt  i     r  cu  i 

-'  (_  Upper  end  of  hbula. 

From  five  to  six  years X  Upper  end  of  radius. 

.  ^    .  1  .  f  I>ower  end  of  ulna. 

At  emhl  years {  ^  .       i.        r  c 

^      -^  ■  \  Lesser  trochanter  of  femur. 

57i 


572  the;  upper  epiphysis  of  the  humerus 

Alter  a  most  exhaustive  study  of  pathological  and  clinical 
material,  both  of  his  own  and  that  of  other  observers,  Poland 
concludes  that  the  order  of  frequency  of  separation  of  the  epiph- 
yses is  about  as  follows : 

1.  The  upper  epiphysis  of  the  humerus. 

2.  The  lower  epiphysis  of  the  femur. 

3.  The  lower  epiphysis  of  the  radius. 

4.  The  lower  epiphysis  of  the  humerus. 

5.  The  lower  epiphysis  of  the  tibia. 

6.  The  upper  epiphysis  of  the  tibia. 

Greater  force  is  necessary  to  cause  a  separation  of  an  epiphysis 
than  is  required  to  cause  a  fracture  of  the  same  bone.  In  child- 
hood severe  traumatism  to  a  joint  will  less  frequently  produce 
a  luxation  of  that  joint  than  a  separation  of  the  epiphysis.  The 
periosteum  remains  attached  to  the  epiphysis  and  is  easily  stripped 
from  the  diaphysis. 

Pain  is  less  in  epiphyseal  separation  than  in  fractures.  This  is 
especially  noticeable  in  separation  of  the  upper  epiphysis  of  the 
humerus.  Pressure  even  very  lightly  over  a  fracture  of  the  upper 
end  of  the  humerus  produces  pretty  severe  pain,  whereas  pressure 
over  a  separated  upper  humeral  epiphysis  does  not  evince  much 
pain.  This  peculiarity  is  in  evidence  in  injuries  to  the  lower  end 
of  the  radius  as  well. 

The  upper  epiphysis  of  the  humerus  is  composed  of  three 
separate  centers  of  ossification:  That  for  the  head,  appearing  at 
tw^o  years ;  that  for  the  great  tuberosity,  appearing  at  three  years ; 
that  for  the  lesser  tuberosity,  appearing  at  four  years.  These 
three  centers  coalesce  to  form  the  upper  epiphysis,  and  it  unites, 
at  from  the  twentieth  to  the  twenty-fourth  year,  to  the  diaphysis 
of  the  humerus.  The  upper  humeral  epiphysis  therefore  includes 
the  two  tuberosities,  the  whole  of  the  head,  and  the  anatomical 
neck.  The  cone-shaped  end  of  the  diaphysis  appears  more  dis- 
tinctly as  age  advances.  In  infancy  the  upper  end  of  the  diaph- 
ysis is  almost  flat  across. 

Separation  of  the  upper  humeral  epiphysis  will  not  necessarily, 
except  in  cases  of  very  great  violence,  open  the  shoulder-joint,  for 
the  capsule  is  firmly  attached  to  the  epiphysis  and  the  synovial 
membrane  is  loosely  attached  to  the  diaphysis.     The  epiphyseal 


Fig.  8,39. — Epiphyses  of  the  scapula  at  five  years  as  shown  by  X-ray.     (X-ray  by  Mr.  Dodd.) 


I'ig.  840.— Epiphyses  of  scapula  at  fourteen  years  as  shown  by  the  X-ray.     (X-ray  by 

Mr.  Dodd.) 

573 


Fig.  841.' — Epiphysis  of  the  upper  end 
of  humerus  at  five  years.  Note  shape  of 
epiphysis.     TX-ray  by  Mr.  Dodd.) 


Fig.  842.' — Epiphysis  of  the  upper  end 
of  the  humerus  at  seven  years.  (X-ray  by 
Mr.  Dodd). 


Fig.  843- — Upper  end  of  humerus  at 
eighteenth  year.  Epiphysis  detached  to 
show  pyramidal  end  of  diaphysis  with  its 
upward  projecting  apex  (after  Poland). 


Fig.  844. — Section  of  upper  end  of  hu- 
merus at  seventeenth  year.  Note  cancel- 
lous structure  and  shape  of  diaphyseal  end 
(after  Poland). 


574 


Fig.  845.' — Vertical  section  of  shoulder-joint.  The  right  half  of  the  figure  represents  the  pos- 
terior half  ;  the  left  the  anterior  half.  E,  Epiphyseal  cartilage,  between  epiphysis  (i)  and  diaphysis 
(2).  3,  Glenoid  cavity  of  scapula,  showing  its  small  size  as  compared  with  that  of  the  head  of  the 
humerus.  4,  Acromion  process.  Above  it  is  seen  the  outer  end  of  the  clavicle.  5,  Cavity  of  shoulder- 
joint,  showing  extent  of  joint  surface  and  synovial  membrane.  6,  Brachial  vessels  and  nerves  (Eisen- 
drath). 


Fig.  846. — Frontal  section  of  lower  end  of  humerus  at  the  age  of  six  and  a  half  years.  Ante, 
rior  half  of  section.  Centers  of  capitellum  and  internal  epicondyle  well  developed.  Actual  size 
(after  Poland). 


575 


Fig.  847.— Detachinciil  ol  the  epiph- 
yses of  the  external  epicondyle  and  of 
thecapitellum.  Age  fifteen  years  (after 
Poland). 


Capitellum. 

Fig.  848. — Drawing  of  separated  lower  humeral 
epiphysis  before  puberty.  The  articular  end  is 
largely  cartilage  (after  Poland). 


Fig.  849. —  Sagittal  section  of  elbow-joint.  Hu- 
mero-ulnar  articulation  at  fifteen  and  one-half 
years.  Note  relation  of  the  synovial  membrane 
to  the  epiphyseal  lines  (after  Poland). 


Fig.  850. — Sagittal  section 
through  the  outer  portion  of  the 
elbow-joint.  Note  relation  of  the 
synovial  membrane  to  the  epiph- 
yseal lines  of  the  bones.  Radiohu- 
meral  articulation  at  fifteen  and 
one-half  years  (after  Poland). 


576 


Fig.  851. — Radius  and    ulnar  epipliyses  at 
five  years.     (X-ray  by  Mr.  Dodd.) 


Fig.  852. — Radius  and  ulnar  epiphyses  at 
seven  years.     (X-ray  by  Mr.  Dodd.) 


Fig.  853. — Frontal  section  through  the  bones  of  the  wrist  and  hand  at  eighteen  years.     Note 
the  relations  of  the  synovial  membranes  to  the  lines  of  the  epiphyses  (after  Poland). 


37 


577 


^Q 


-  X 


578 


Fig.  856. — -Epiphyses  of 
upper  end  of  the  femur  at  five 
years.     (X-ray  by  Mr.  Dodd.) 


Fig.  857. — Frontal  section  of  left  hip-joint  in  a  boy  seventeen 
and  one-half  years  old.  Note  relation  of  synovial  membrane  to 
the  epiphyseal  lines  (after  Poland). 


Fig.  858. — Epiphyses  of  the 
upper  end  of  the  femur  at  seven 
years.    (X-ray  by  Mr.  Dodd.) 


Fig.  859, — Epiphyses  of  the  upper  end  of  the  femur 
at  fourteen  years.     (X-ray  by  Mr.  Dodd.) 

579 


Fig.  860.  —  Lower  epiphysis  of    femur.      Upper  epipliysis   of  tibia  and  fibula  at  five  years 
(X-ray  by  Mr.  Dodd  and  Dr.  Osgood.) 


Fig.  861. — Lower  epiphysis  of  the  young  adult  femur.     (X-ray  by  Mr.  Dodd.) 

580 


Fig.  862. — Lower  epiphj'sis  of  the  femur  at  fif- 
teen years.     (X-ray  by  Mr.  Dodd.) 


Fig.  863. — ^Upper  epiphysis  of  tibia  at  five 
years.     (X-ray  by  Mr.  Dodd.) 


Fig.  864 — Upper  epiphysis  of  tibia  at  seven 
years.     (X-ray  by  Mr.  Dodd.) 


Fig.  865. — Upper  epiphysis  of  tibia  at  fourteen 
years.    (X-ray  by  Mr.  Dodd.) 


Fig.  866. —  Lateral  view  of  the  upper  epiphysis  of 
the  tibia.  Note  the  bony  connection  of  tibial  tubercle 
center  with  upper  tibial  epiphysis. 


Fig.  867. — Epiphysis  of  the  lower 
end  of  tibia  at  seven  years.  (X-ray  by 
Mr.  Dodd.) 


Fig.  868. — Epiphysis  of  the  lower  end 
of  the  tibia  at  fourteen  years.  (X-ray  by 
Mr.  Dodd.) 


Fig.  860. — Epiphyses  of  the  normal  lower  end  of 
tibia  and  fibula.  Child  aged  five.  (X-ray  by  Mr. 
Dodd.) 


582 


LOWER   EPIPHYSIS   OF   THE   RADIUS 


583 


line  is  intra-articular  upon  the  inner  side  only.  In  the  adult 
the  epiphyseal  line  marks  the  upper  limit  of  the  surgical  neck. 
The  growth  in  the  length  of  the  shaft  of  the  humerus  occurs  from 
the  upper  humeral  epiphysis.  Conical  stump  cases  following  am- 
putation of  the  upper  arm  illustrate  how  active  the 
upper  epiphysis  is  in  the  growth  in  length  of  the 
humerus. 

The  lower  epiphysis  of  the  femur,  the  largest 
epiphysis  in  the  body,  appears 
before  birth,  attains  a  good  size 
by  two  years,  and  unites  to  the 
diaphysis  at  from  the  twentieth 
to  the  twenty-third  year. 

The  adductor  tubercle  is  on 
the  diaphysis  marking  the  level 
of  the  line  of  the  epiphysis  upon 
the  inner  side  of  the  femur.  The 
two  heads  of  the  gastrocnemius 
muscle  are  attached  to  both  the 
epiphysis  and  the  diaphysis,  but 
chiefly  to  the  diaphysis.  The 
plantaris  is  attached  to  the  di- 
aphysis. Both  of  these  muscles, 
in  a  separation  of  the  epiphysis, 
are  stripped  from  the  shaft  with 
the  periosteum,  and  act  solely  on 
the  detached  epiphysis,  causing 
it  to  rotate  upon  its  transverse 
axis.  In  separations  without  much  displacement 
the  knee-joint  is  not  opened.  The  quadriceps  bursa 
may  escape  injury. 

The  lower  epiphysis  of  the  radius  appears  about  the  second 
year,  and  unites  to  the  shaft  at  from  the  nineteenth  to  the 
twentieth  year. 

The  synovial  membrane  of  the  wrist-joint  does  not  touch  the 
epiphyseal  line  of  the  radius  either  anteriorly  or  posteriorly.  It 
takes  its  origin  from  the  lower  articular  margin  of  the  epiphysis. 
The  synovial  membrane  of  the  inferior  radio-ulnar  articulation 


/ 


Fig.  870. — Epiph- 
ysis (lower)  of  fibula  at 
fourteen  years.  (X-ray 
by  Mr.  Dodd.) 


Fig.  S71. — Ep- 
iphyses of  fibula  at 
five  years.  (X-ray 
by  Mr.  Dodd.) 


584  ANATOMICAL   FACTS    REGARDING    THE    EPIPHYSES 

extends  above  the  epiphyseal  hnes  of  both  the  radius  and  ulna. 
It  is  loosely  connected  with  the  diaphysis  of  each  bone.  In 
epiphyseal  separations  laceration  of  the  synovial  pouch  is  possi- 
ble, but  is  not  absolutely  inevitable. 

The  lower  epiphysis  of  the  humerus  is  formed  from  three 
separate  centers  of  ossification — viz.,  the  capitellum,  which  ap- 
pears at  three  years ;  the  trochlea,  which  appears  at  eleven  years ; 
the  external  epicondyle,  which  appears  at  thirteen  vears.  These 
three  centers  coalesce  at  about  the  fifteenth  year,  to  form  the 
lower  humeral  epiphysis.  The  epiphysis  unites  to  the  diaphysis 
at  about  the  seventeenth  year.  The  epiphysis  for  the  internal 
epicondyle  forms  no  part  of  the  lower  humeral  epiphysis.  It 
appears  at  about  the  fifth  year,  and  joins  the  diaphysis  at  from 
the  eighteenth  to  the  twentieth  year. 

The  synovial  membrane  at  about  the  fifteenth  year  and  after- 
ward overlaps  the  epiphyseal  line.  The  epiphyseal  line  is  a  little 
higher  on  the  outer  side  than  on  the  inner.  It  inclines  obliquely 
downward  and  inward.  The  epiphysis  is  thinner  internally  than 
externally. 

The  epiphysis  of  the  lower  end  of  the  tibia  appears  about  the 
second  ^-ear,  and  unites  to  the  diaphysis  about  the  eighteenth 
or  nineteenth  5^ear.  Neither  anteriorly  nor  posteriori}^  does  the 
synovial  membrane  come  in  contact  with  the  epiphyseal  line,  so 
that,  unless  great  violence  is  exercised  or  the  epiphysis  is  frac- 
tured, the  ankle-joint  is  unopened  in  separation  of  this  epiphysis. 

The  epiphysis  of  the  upper  end  of  the  tibia  appears  at  about 
the  first  3^ear,  and  unites  to  the  shaft  at  the  twentieth  or  twenty- 
second  year.  The  synovial  membrane  is  quite  a  little  distance 
from  the  line  of  the  epiphysis.  The  epiphyseal  line  runs  quite 
close  to  the  superior  tibiofibular  articulation. 

The  acromion  process  of  the  scapula  presents  an  epiphj^sis 
that  appears  at  from  the  fourteenth  to  the  sixteenth  year,  and 
unites  at  from  the  twenty-second  to  the  twenty-fifth  year.  The 
epiphysis  includes  the  oval  articular  facet  for  the  clavicle.  The 
coracohumeral  and  acromioclavicular  ligaments  are  attached  to 
it.  The  epiphysis  joins  the  acromion  behind  the  acromiocla- 
vicular joint. 


CHAPTER   XIX 
GUNSHOT  FRACTURES  OF  BONE 

The  civil  surgeon  rarely  has  opportunity  to  study  the  effect 
upon  bone  of  bullet  wounds.  He  may  see  in  his  practice  a  few 
gunshot  fractures.  His  experience  is  necessarily  limited.  The 
facts  contained  in  this  brief  chapter  are  taken  from  the  experience 
of  such  military  surgeons  as  Kocher,  Treves,  Nancrede,  Makins, 
Senn,  Borden,  Ta  Garde,  and  others  who  have  during  the  past 
few  years  studied  scientifically  this  important  class  of  wounds. 

In  the  construction  of  the  modern  militarj^  rifle  several  impor- 
tant changes  have  been  made.  The  bore  of  the  rifle  has  been  re- 
duced. The  caliber  of  the  bullet  has  been  lessened.  The  velocity 
of  the  bullet  at  the  muzzle  has  been  increased.  The  trajectory 
is  more  flat.  The  revolution  of  the  bullet  upon  its  long  axis  is 
increased. 

As  a  general  result  of  these  various  changes  the  modern  military 
rifle  has  a  great  range  and  great  accuracy.  The  effect  of  the 
modern  bullet  upon  bone  is  described  as  concisely  as  is  possible  in 
the  following  paragraphs. 

The  amount  of  the  damage  done  to  bone  is  dependent  upon 
several  factors:  The  greater  the  velocity  of  the  bullet  when  the 
bone  is  struck,  the  greater  will  be  the  destruction  of  the  bone. 
The  muzzle  velocity  of  the  modern  bullet  is  ordinarily  about  two 
thousand  feet  a  second.  The  less  the  velocity,  the  less  will  be  the 
destructive  effects.  The  velocity  may  be  just  sufficient  to  break 
the  bone  and  not  to  carry  the  bullet  through  the  limb.  The 
severity  of  the  injury  therefore  decreases  in  proportion  to  the  dis- 
tance which  intervenes  between  the  rifle  and  the  object  struck. 
The  trained  military  surgeon  may  read  the  range  in  the  character 
of  the  damage  done.  The  more  pointed  bullet  secures  for  itself 
greater  penetration  and  perforation.  The  bullet  acts  like  a  steel 
wedge  driven  with  great  velocity  through  the  soft  and  hard  parts. 

5«5 


586 


GUNSHOT   FRACTURES    OF    BONK 


The  primary  collision  area  is  small.  The  only  indisputable  evi- 
dence of  a  low  velocity  is  the  lodgment  of  an  undeformed  bullet. 
The  resistance  offered  by  the  tissues  is  lessened  and  the  resulting 


Fig.  872. — Sections  of  bullets  to  show  relative  shape  and  thickness  of  mantles  :  i,  Geudes  : 
regular  dome-shaped  tip  ;  mild  steel  mantle ;  thickness  at  tip,  0.8  mm. ;  at  sides  of  body,  0.3 
mm.;  2,  Lee-Metford  :  ogival  tip;  cupro-nickel  mantle;  thickness  at  tip,  0.8  mm.;  gradual 
decrease  at  sides  to  0.4  mm.  ;  3,  Mauser  :  pointed  dome  tip  ;  steel  mantle  plated  with  copper 
alloy;  thickness  at  tip,  0.8  mm.;  gradual  decrease  at  sides  to  0.4  mm.;  4,  Krag-Jorgensen  : 
ogival  tip  as  in  Lee-Metford  ;  steel  mantle  plated  with  cupro-nickel ;  thickness  at  tip,  0.6 
mm. ;  gradual  decrease  at  sides  to  0.4  mm.  Note  the  more  gradual  thinning  in  the  Lee- 
Metford  (from  Makins'  "Surgical  Experiences,"  etc.). 


Fig-  873. — Four  common  types  of  lateral  Mauser  ricochet  bullets  (from  Makins'  "  Surgical 

Experiences,"  etc.). 


wounds  are  neat.  Important  parts  are  seemingly  miraculously 
avoided  by  the  bullet.  The  revolution  of  the  bullet  on  its  long 
axis  facilitates  a  neat  wound  of  entrance  through  the  skin.  The 
Mauser  bullet  revolves  on  its  own  axis  once  in  83^  inches,   or 


GUNSHOT  FRACTURES   OF   BONE 


587 


about  half  of  a  full  revolution  in  the  perforation  of  a  limb.  The 
amount  of  destruction  suffered  by  any  part  of  a  bone  depends 
primarily  upon  the  amount  of  resistance  which  it  opposes  to  a 
bullet.  There  is  more  resistance  offered  by  the  cortex  found  in 
the  shaft  than  by  the  spongy  tissue  of  the  ends  of  the  long  bones. 
When  the  hard  shaft  or  cortical  bone  is  hit,  the  force  of  the  bullet  is 
expended  in  breaking  this  dense  and  resistant  bone  into  minute 
pieces. 

The  explosive  effect  of  a  bullet  is  dependent  upon  the  velocity 
remaining  to  be  expended  upon  the  small  particles  of  bone  broken 
off  by  the  initial  impact.  The  carrying  of  these  particles  of  bone 
forward  into  and  through  the  tissues  causes  the  laceration  and 
tearing  so  characteristic  of  the  so-called  explosive  effect  of  a 


Fig.  874. — -Five  types  of  fracture  :  a,  Primary  lines  of  stellate  fracture  ;  b,  development  of 
the  same  lines  by  a  bullet  traveling  at  a  low  degree  of  velocity  ;  the  two  left-hand  limbs  seen 
in  (a)  absent ;  in  their  places  is  seen  a  transverse  line  ;  c,  typical  complete  wedge  ;  d,  incom- 
plete wedge;  e,  oblique  single  line  (from  Makins'  "  Surgical  Experiences,"  etc.). 


bullet.     The  detached  bony  particles  become  really  secondary 
missiles. 

Kocher  has  classified  the  parts  of  the  long  bones  injured  as  the 
diaphysis,  the  epiphysis,  and  the  part  between  the  two,  the  met- 
aphysis.  The  cortical  layer  of  the  metaphysis  is  thin  and  the 
spongy  tissue  is  in  evidence.  Uncomplicated  injuries  of  these 
three  parts  of  the  bone  are  usually  quite  characteristic  (see  Figs. 
874,  881,  889).  The  flat  bones  show  a  clean  perforating  wound 
similar  to  that  seen  in  the  short  bones.  The  cancellous  or  spongy 
tissue  of  bone  is  ordinarily  perforated  completely  and  the  wound 
of  the  bone  is  usually  pretty  clean-cut.  Clean-cut  perforations 
without  fracture  are  the  rule  in  the  neighborhood  of  the  joints  and 
epiphyses  (see  Figs.  877-880).     Makins  noticed  in  South  Africa, 


588 


GUNSHOT  FRACTURES  OF  BONE 


among  the  wounds  he  studied,  "the  striking  contrast  of  clean 
perforation  and  extreme  comminution  in  different  cases";  "the 
occasional  occurrence  of  fracture  of  a  very  high  degree  of  longi- 
tudinal obliquity" ;  "the  rarity  of  any  that  could  be  termed  trans- 
verse fractures";  "the  general  tendency  of  longitudinal  fissuring, 
when  it  occurred,  to  stop  short  of  the  articular  extremities  of  the 
bones."     If  explosive  effects  are  but  slightly  marked  it  is  probably 


Fig-  S75.— Diagrammatic  view  of  a  type 
of  fracture  of  the  femur,  the  bullet  entering 
on  the  anterior  surface  of  the  bone  caus- 
ing extensive  longitudinal  fissuring  of  the 
shaft.  The  articular  ends  of  the  same  have 
not  been  involved  in  the  fracture  (after 
Kocher). 


Fig.  876. — -Diagram  of  a  type  of  frac- 
ture. The  entrance  wound  clean-cut,  the 
exit  wound  lacerated  and  larger  than  the 
wound  of  entrance  (after  Kocher). 


because  the  velocity  remaining  was  insufficient  to  impart  enough 
motion  to  the  detached  particles  to  convert  them  into  secondary 
missiles.  The  greater  the  distance  between  the  rifle  and  the 
bone  struck,  the  lower  will  be  the  velocity  of  the  bullet.  Conse- 
quently the  splinters  of  bone  will  be  fewer,  longer,  and  more  ad- 
herent. On  the  contrary,  the  nearer  the  bone  to  the  rifle,  the 
splinters  will  be  more  numerous,  shorter,  unattached,  and  pul- 
verized with  bone  sand. 


Fig.  877. — Upper  end  of  tibia  penetrated 
by  bullet,  showing  clean-cut  wound  with- 
out laceration  of  bone  (La  Garde). 


Fig.  878. — Upper  end  of  tibia  penetrated 
by  bullet.  Slight  fissure  of  shaft  below 
bullet  hole  (La  Garde). 


Fig.  879- — Anterior  surface  lower  end  Fig-  880.— Posterior  view  of  Fig.  879- 

of   femur.    Clean-cut  wound  of  entrance,  Exit   wound.      Note    more    comminution 

fissure  (La  Garde).  than  at  point  of  entrance  (La  Garde). 


590 


GUNSHOT  FRACTURES   OF   BONH 


A  small  skin  wound  may  conceal  a  serious  injury  to  the  bone 
beneath.  The  flesh  wounds  of  entrance  inflicted  by  the  modern 
rifle  are  mostly  trivial.  The  missile  with  its  great  velocity,  in 
face  of  slight  resistance,  will  retain  nearly  all  its  energy,  imparting 
little  or  none  to  the  tissues.  The  exit  wound  may  be  small  or 
large,  depending  upon  the  presence  or  absence  of  the  explosive 
effect  and  also  upon  the  deflection  of  the  bullet.  Deflection  of  the 
bullet  at  the  distance  at  which  many  wounds  are  received,  as 


*>»-uy4/W 


Fig.  SSi. — Diagram  of  a  bullet  wound  of  the  metaphysis  of  the  femur.  The  smaller  en- 
trance wound  contrasts  with  the  larger  e.xit  wound.  The  absence  of  Assuring  is  rather  char- 
acteristic of  bullet  wounds  in  this  region  of  the  ends  of  the  bones  (after  Kocher). 


pointed  out  by  Nancrede,  occurs  more  commonly  than  is  taught. 
Between  the  discharge  of  a  bullet  and  its  arrival  at  the  mark  many 
things  may  happen  to  it,  resulting  in  a  complicated  wound  of  the 
soft  parts  and  an  extensive  comminution  of  bone. 

The  turning  of  a  bullet  by  impact  with  an  obstacle  in  its  course 
is  spoken  of  as  ricochet.  The  bullet  which  ricochets  may  enter  the 
body  not  necessarily  end  on,  but  in  any  position  and  wobbling 
about.  Under  these  circumstances  the  wound  of  entrance  is 
greatly  increased,    and,   the  velocity  being  impaired,   a  lodged 


GUNSHOT   FRACTURES    OF    BONE 


591 


bullet  often  results.  However,  if  great  velocity  remains,  a 
ricocheting  bullet  may  cause  very  great  damage.  A  ricochet 
bullet  is  dangerous  because  its  penetrative  power  is  diminished, 
it  is  liable  to  be  retained  in  the  tissue,  serious  damage  results  to 


Fig.  882. — Gutter  fracture  of  second  degree,  perforating  the  skull  in  the  center  of  its 
course.  The  external  table  alone  carried  away  at  either  end  (from  Makins'  "Surgical  Ex- 
periences," etc.). 


Fig.  883. — Illustrating  the  penetrating  power  of  bullets  of  different  material  in  oak  timber 
at  right  angles  to  grain  of  the  wood  (La  Garde). 


the  bone  if  it  is  struck,  and  a  badly  lacerated  wound  may  result 
in  the  soft  parts. 

These  facts  are  perhaps  of  interest :  The  old  flint-lock  ball  was 
■j^  inch  in  diameter.  The  Minie  rifle  (Crimean)  ball  was  yV  inch 
in  diameter.  Martini  Henry  ball  was  yu  inch  in  diameter.  The 
modern    small    bore    Lee-Metford  is  j\  inch   in   diameter.     The 


592 


GUNSHOT   FRACTURES   OF    BONE 


Mauser  is  slightly  smaller  than  the  latter.  The  latter  two  bullets 
have  the  new  cupro-nickel  case.  The  others  were  the  old  lead 
bullets.  The  Mauser  bullet  is  1.2 1  inches  long,  weighs  172.8 
grains,  is  0.275  inch  in  diameter,  has  a  muzzle  velocity  of  238  feet 
per  second,  and  makes  i  turn  to  the  left  every  9  inches.  The 
English  Lee-Metford  is  1.25  inches  long,  weighs  215  grains,  is  0.303 
inch  in  diameter,  and  has  a  muzzle  velocity  of  2000  feet  per  second. 
As  La  Garde  has  justly  remarked,  the  employment  of  smokeless 
powder,  a  flatter  trajectory  and  greater  penetration,  and  the 
change  to  the  smaller  jacketed  projectiles  will  increase  the  number 
of  the  wounded  in  war,  but  the  wounds,  as  a  whole,  will  be  less 


Fig.  S84. — Diagrammatic  transverse  section  of  complete  gutter  fracture:  A,  External 
table  destroyed,  large  fragment  of  internal  table  depressed  (low  velocity  or  dense  bone) ; 
£,  pulverization  and  comminution  of  both  tables  at  the  center  of  the  track  ;  C,  depression  of 
inner  table  (low  velocity)  (from  IMakins'  "  Surgical  Experiences,"  etc.). 


grave — more  humane.  Soldiers  will  be  more  often  restored  to  the 
State  useful  members  of  the  community,  instead  of  cripples  and 
pensioners.  In  point  of  economy  the  new  projectiles  confer  a 
great  advantage. 

Treatment. — The  principles  underlying  the  treatment  of  closed 
fractures  are  to  be  followed  in  the  case  of  gunshot  fractures.  But 
there  are  a  few  considerations  worthy  of  note.  Avoid  exploration 
of  a  fresh  gunshot  fracture  upon  the  field.  Local  examination  to 
determine  the  number,  size,  and  position  of  fragments  is  unwise. 
The  modern  bullet  is  usually  aseptic,  smooth,  and  not  heated. 
There  is  no  urgency  for  its  removal.     It  appears  (Borden)  that 


TREATMENT  593 

neither  ricochet  passage  through  other  objects  nor  lowered  veloc- 
ity markedly  increases  the  proneness  of  the  jacketed  missile  to 
produce  infection.  The  lodgment  of  a  bullet  does  not  necessitate 
the  treatment  of  the  wound  as  if  it  were  an  infected  one.  The 
dictum  of  von  Nussbaum — "The  fate  of  the  wounded  rests  in  the 
hands  of  the  one  who  applies  the  first  dressing" — applies  nowhere 


Fig.  885.— Clean  gutter  fracture  of  the  ilium  (range  about  300  yards).  The  gutter  was 
clean-cut  and  admitted  the  forefinger.  The  inner  and  outer  tables  of  the  bone  were  in  part 
blown  out  of  a  large,  irregularly  circular  e.xit  opening  about  i^  inches  above  the  crest  of  the 
ilium.  The  cancellous  tissue  was  probably  entirely  blown  out.  Plates  of  the  outer  and  inner 
tables  still  remained  connected  by  their  periosteum  to  that  deep  aspect  of  the  iliacus  and 
gluteus  medius  muscles.  The  peritoneal  cavity  was  not  opened.  The  patient  did  well. 
Compare  with  gutter  fracture  of  the  skull,  seen  in  figure  882  (from  Makins'  "  Surgical  Ex- 
periences," etc.). 

with  as  much  force  as  to  the  wounded  in  battle.  The  first  field 
dressing  is  of  the  greatest  importance. 

Consideration  of  gunshot  traumatism  of  the  shaft  of  long  bones, 
as  shown  by  the  Rontgen  ray  in  connection  with  the  ultimate  out- 
come of  the  cases,  points  indubitably  to  the  conclusion  that  in- 
fection or  noninfection  of  the  wound  should  influence  treatment, 
rather  than  the  amount  or  extent  of  bone  damaged  (Borden). 

In  noninfected  wounds  extensive  comminution  is  not,  as  a  rule, 
38 


594  GUNSHOT   FRACTURES    OF    BONE 

an  indication  for  operative  interference  of  any  kind.  Occlusive 
dressings  and  immobilization  give  assurance  of  the  best  possible 
results.  Where  there  is  considerable  comminution  shortening  of 
the  limb  will  probably  occur  as  a  result  of  the  comminution  and 
the  displacement  of  the  bone  fragments.  But  excellent  functional 
use  of  the  limb  may  be  restored,  unless  the  lesion  of  the  soft  parts 
is  extensive  and  motion  is  restricted  by  the  formation  of  cicatricial 
connective  tissue  in  the  traumatic  spaces  (Borden). 

Where  infection  exists  removal  of  the  cause  under  aseptic  or 
antiseptic  precautions  is  indicated.  In  such  cases  complete 
cleansing  of  the  wound  and  removal  of  all  loose  bone  fragments, 
followed  by  drainage  and  antiseptic  dressings  and  irrigation,  will 


Fig.  886. — Superficial  perforating  fracture,  illustrating  lifting  of  the  roof  at  both  entry  and 
exit  openings  (from  Ma:kins'  "Surgical  Experiences,"  etc.). 

usually  suffice,  and  excision  or  amputation  will  only  have  to  be 
resorted  to  in  extreme  cases  (Borden).  Amputation  for  extensive 
fracturing  of  the  long  bones  is  almost  unknown  (Nancrede). 

As  to  the  disinfection  of  the  limb,  primary  cleansing,  mainly  by 
soap  and  water,  of  course  should  precede  the  exploration;  and 
when  the  latter  has  been  carried  out,  a  second  cleansing,  prefer- 
ably with  corrosive  sublimate,  is  imperative. 

Immobilization  is  a  more  difficult  problem.  Makins'  remarks: 
A  question  of  constant  difficulty  is  that  of  frequency  of  dressing. 
In  a  stationary  or  base  hospital  this  is  not  difficult.  When  the 
patient  is,  however,  being  moved  from  the  field  to  the  stationary 
hospital,  and  thence  to  the  base,  the  movements  during  transport 


TREATMENT  595 

disturb  the  fixity  of  the  dressing.  No  fractures  of  the  thigh  or 
leg,  and  few  of  the  arm,  can  be  transported  for  any  distance  with- 
out material  disadvantage. 

If  possible,  all  fractures  of  the  arm,  thigh,  or  leg  should  be  kept 
at  a  stationary  hospital  for  a  period  of  three  or  more  weeks. 

The  necessity  for  primary  amputation  chiefly  depends  on  the 
nature  of  the  injury  to  the  soft  parts,  less  commonly  on  the  extent 
of  the  injury  to  the  bones,  and  should  be  decided  on  exactly  the 
same  lines  as  in  civil  practice.  So-called  intermediate  amputa- 
tions are  always  to  be  avoided  if  possible.  The  results  have 
been  bad  and  the  operation  should  only  be  undertaken  in  cases 
of  severe  sepsis  where  little  can  be  hoped  from  it,  or  for  secondary 
hemorrhage.  When  the  operation  could  be  tided  over  until  the 
septic  process  had  settled  down  and  localized  itself,  secondary 
amputation  gave  very  fair  results.     In  either  intermediate  or 


Fig.  887. — Diagrammatic  longitudinal  section  of  fracture  shown  in  figure  886  (from  Makins' 
"  Surgical  Experiences,"  etc.). 


secondary  amputation  for  suppurating  fractures  it  was  necessary 
to  bear  in  mind  the  special  likelihood  of  an  extensive  osteomye- 
litis (Makins). 

The  very  great  mortality  attending  gunshot  fracture  of  the 
femur  previous  to  the  introduction  of  the  small-bore  rifle  makes  it 
important  to  consider  this  fracture  in  some  detail.  I  quote 
Makins  as  having  had  the  best  recorded  clinical  experience  in 
these  cases. 

First  with  regard  to  the  primary  signs  and  symptoms.  A  very 
considerable  degree  of  general  or  constitutional  shock  usually 
accompanied  them,  and  this  was  perhaps  more  constant  than  in 
the  case  of  any  other  injury  in  the  body.  Local  shock  to  the  part 
was  also  a  prominent  feature.  Abnormal  mobility  was  very  free 
in  the  badly  comminuted  cases.  Crepitus  was  often  loose,  and  of 
the  "bag-of-bones"  variety.  The  result  of  local  shock  and  con- 
sequent flaccidity  of  the  muscles  was  to  reduce  the  development 


596 


GUNSHOT  FRACTURES  OF  BONE 


of  primary  shortening;  in  some  cases  of  severe  comminution  this 
was  practically  nil  during  the  first  day  or  two,  when,  with  return 
of  tone  in  the  muscles,  it  sometimes  became  very  considerable. 

The  long  and  difficult  transport  is  the  most  unsatisfactory 
element  to  contend  with  in  the  treatment  of  fractures  of  bone  in 
the  field.  There  are  advantages  in  having  a  field  hospital  behind 
the  firing  line.     Sir  Wm.  MacCormac  has  said  that  the  ideal  treat- 


Fig.  888.— Perforation  of  lower 
third  of  tibia,  showing  Ufting  and 
fissuring  of  the  compact  roof  of  the 
tunnel.  Compare  with  figure  886, 
of  a  fracture  of  the  cranial  vaults 
(from  Makins'  "  Surgical  Experi- 
ences "  etc.). 


Fig.  889. — Oblique  perforation,  implicating  both 
epiphysis  and  diaphysis.  Large  fragment  detached 
at  exit  aperture.  Caused  by  a  bullet  traveling  at 
a  low  rate  of  velocity.  The  dotted  lines  indicate 
the  course  of  the  track  (from  Makins'  "  Surgical 
Experiences,"  etc.). 


ment  of  a  gunshot  fracture  of  the  femur  would  be  to  erect  a  tent 
over  the  man  where  he  fell  and  not  to  transport  him  at  all. 

The  plaster-of- Paris  splint  (roller  bandage)  spica  to  both  thighs, 
with  a  long  outside  splint  from  axilla  to  below  the  foot,  is  the  most 
satisfactory  immobilization  apparatus  for  these  cases  of  compound 
thigh  fracture. 

The  operative  mortality  following  compound  or  open  fractures 
of  the  femur  during  the  Crimean  war  was  about  73  per  cent.  Dur- 
ing the  American  war  it  was  about  53  per  cent.  During  the 
Franco-German  war  it  was  65  per  cent,  among  the  Germans  and 
90  per  cent,  among  the  French.     The  conservative  mortality — 


PROGNOSIS   IN    FRACTURES   OF   FEMUR  597 

i.  e.,  in  the  unoperated  cases — was,  under  these  same  conditions: 
Crimean  war,  72  per  cent. ;  American  war,  49  per  cent. ;  Franco- 
German:  German,  28  per  cent.;  French,  9  per  cent.  In  the  re- 
cent war  with  Spain  in  Cuba,  although  the  results  are  not  all 
tabulated,  during  1898-99  the  general  mortality  in  operated  and 
unoperated  cases  together  was  but  10  per  cent,  in  this  serious 
injury.  Modern  surgical  methods  used  upon  wounds  of  bone 
caused  by  modern  military  weapons  will  bring  the  mortality-rate 
very  low  indeed.  All  those  interested  in  this  department  of 
surgery  will  await  final  statistics  with  hopeful  expectation. 

Prognosis  in  Fractures  of  the  Femur. — From  Makins'  "Sur- 
gical Experiences"  :  "As  regards  mortality,  fractures  in  the  upper 
third  of  the  bone  proved  one  of  the  most  formidable  injuries  which 
came  under  treatment.  Suppuration  was  common,  at  least  60 
per  cent,  of  the  wounds  becoming  infected.  This  depended  on 
several  reasons,  often  inseparable  from  the  injuries,  or,  from  their 
treatment  in  field  hospitals;  such  as  (i)  the  exit  wound  being 
situated  in  the  dangerous  region  of  the  thigh;  (2)  ineffective  dress- 
ing and  fixation ;  (3)  the  impossibility  of  insuring  primary  cleansing 
and  removal  of  detached  fragments  of  bone;  (4)  the  necessity  of 
the  early  transport  of  patients  to  the  stationary  or  base  hospitals, 
often  for  great  distances;  (5)  the  comparatively  long  period  that 
often  had  to  elapse  before  the  opportunity  of  doing  the  first  effi- 
cient dressing  arrived.  Fractures  in  the  middle  and  lower  thirds 
of  the  bone  were  more  easy  to  treat  successfully,  but  these  also 
added  to  the  list  both  of  amputation  and  fatalities.  Punctured 
fractures  of  the  lower  articular  extremity  were  usually  of  little 
importance,  as  they  progressed  without  exception,  as  far  as  my 
experience  went,  favorably." 


CHAPTER   XX 

THE  RONTGEN  RAY  AND  ITS  RELATION  TO 
FRACTURES 

BY  E.  A.  CODMAN,  M.D. 

On  January  23,  1896,  Rontgen  read  his  announcement  of  the 
discovery  of  the  X-rays  before  the  Physico-medical  Society  at 
Wurzburg.  The  extraordinary  news  fled  over  the  world  in  an 
incredibly  short  time.  Within  a  few  months  skiagraphs  of  the 
bones  of  the  hands  appeared  in  every  newspaper  that  could  afford 
an  illustration,  and  the  reporters  indulged  their  imaginations  and 
dwelt  on  the  advantages  the  new  discovery  would  bring  to  medi- 
cine and  surgery.  The  strangeness  of  the  subject  offered  an  un- 
usually brilliant  field  for  the  imaginative  and  humorous,  and  in 
consequence  it  will  undoubtedly  be  years  before  the  public  is  dis- 
abused of  its  first  erroneous  impressions.  Perhaps  more  people 
err  now  on  the  side  of  incredulity  than  credulity,  and  are  inclined 
to  regard  the  wonders  they  heard  of  at  first  as  "newspaper  talk." 
Medical  men  are  particularly  subject  to  this  criticism,  and  there 
are  many  who  seem  to  feel  a  disappointment  in  the  results.  It  is 
unfortunate  that  Rontgen's  original  article  was  not  widely  pub- 
lished in  the  first  place,  for  it  is  a  model  of  scientific  accuracy,  and 
contains  not  a  single  statement  that  has  not  been  substantiated 
again  and  again.  To  those  men  who  understood  the  limitations 
of  the  X-ray  that  this  article  pointed  out,  the  results  have  not 
been  disappointing.  On  the  contrary,  the  improvements  in  appa- 
ratus and  technic  have  enlarged  the  scope  of  its  use  and  increased 
the  importance  of  the  information  it  gives  us.  The  X-ray  depart- 
ment has  become  a  necessity  in  every  general  hospital. 

In  discussing  the  value  of  Rontgen's  discovery  in  a  book  on  the 
treatment  of  fractures  it  has  seemed  wise  to  point  out  some  of  the 
mistakes  that  are  commonly  made  in  the  interpretation  of  skia- 
graphs.    To  those  who  have  done  practical  work  with  the  X-rays 

598 


MISTAKES  IN  INTERPRETATION  OF  SKIAGRAPHS      599 

this  chapter  will  be  valueless;  but  those  who  have  not  may  find 
in  it  some  assistance  in  their  effort  to  learn  what  real  value  the 
new  science  is  to  this  branch  of  surgery. 

Among  other  misconceptions  the  Crookes  tube  was  supposed 
to  emit  a  very  powerful  light.  It  is  not  a  powerful  light,  but 
merely  a  faint  one  of  such  quality  that  it  is  able  to  penetrate  sub- 
stances that  ordinary  light  does  not.  It  is  its  peculiar  quality,  not 
its  intensity,  that  enables  it  to  penetrate  opaque  objects.  It  is 
invisible  to  our  eyes,  but  has  the  quality  of  causing  chemical  action 
on  a  photographic  plate  or  of  affecting  crystals  of  certain  sub- 
stances so  as  to  make  them  emit  a  faint  light.  A  sort  of  sand- 
paper made  of  these  crystals,  finely  ground,  forms  a  fluorescent 
screen.  A  fluoroscope  is  made  by  inclosing  such  a  screen  in  a 
light  tight  box  with  an  eyepiece  to  allow  the  observer  to  see  the 
crystal  side  of  the  sand-paper.  When  this  instrument  is  brought 
near  a  Crookes  tube  in  action,  the  crystals  become  luminous  and 
any  substance  that  is  not  easily  penetrated  by  these  rays,  when 
placed  between  the  source  of  light  and  the  screen,  will  cut  off  the 
rays  and  cast  a  shadow  on  the  sand-paper  that  can  be  seen  on  the 
side  away  from  the  object.  This  shadow  will  be  more  or  less  deep, 
according  to  whether  the  substance  cuts  off  more  or  less  rays. 
Thus,  iron  casts  a  darker  shadow  than  wood;  bone,  a  darker 
shadow  than  flesh.  In  general  the  opacity  of  different  substances 
varies  directly  with  their  atomic  weights.  In  the  same  way  the 
substance  placed  between  the  source  of  light  and  a  photographic 
plate  will  cut  off  some  of  the  rays  from  the  plate.  Where  these 
are  cut  off,  chemical  action  does  not  occur ;  where  some  of  the  rays 
go  through  it  occurs  slightly;  where  the  object  does  not  interfere 
at  all  and  the  rays  strike  the  plate  directly,  the  action  is  greatest. 
When  the  plate  is  developed,  we  get  a  picture  of  the  shadow  of  the 
object  with  its  most  dense  parts  most  deeply  shaded. 

Many  people  confuse  an  X-ray  picture  with  a  photograph. 
They  take  it  to  be  a  photograph  by  X-ray  light.  It  is  not  a  photo- 
graph, but  a  shadow-picture,  a  compound  silhouette,  a  projec- 
tion of  the  parts  of  an  object.  A  photograph  of  the  hand  is  made 
by  the  light  reflected  from  the  hand  to  the  photographic  plate,  and 
shows  the  surface  of  the  skin.  A  skiagraph  of  the  hand  is  made 
by  the  light  that  has  passed  through  the  hand,  and  shows  a  chart  of 


6oO   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

the  different  densities  of  the  different  constituents  of  the  hand,  as 
bone,  muscle,  fat,  and  skin.  As  the  other  parts  of  the  hand  are  of 
about  equal  density  and  this  density  is  much  less  than  that  of  bone, 
the  bones  appear  prominently  on  the  chart.  The  thickest  portions 
and  most  dense  portions  of  the  bone  appear  more  deeply  marked 
than  the  lighter  and  spongy  portions.  As  every  little  gradation  of 
density  is  registered,  the  whole  forms  a  picture. 

As  far  as  we  know,  the  effects  of  the  X-rays  are  only  obtainable 
in  the  immediate  neighborhood  of  their  course;  that  is,  a  small 
point  on  the  platinum  reflector  in  the  Crookes  tube.  From  this 
point  they  radiate  in  all  directions,  their  power  gradually  dimin- 
ishing until  at  a  distance  of  about  a  hundred  feet  or  a  little  more 
they  are  not  appreciable  by  any  means  now  at  our  command. 
Practically,  they  are  only  strong  enough  for  skiagraphic  purposes 
within  a  few  feet  of  the  tube. 

Since  they  proceed  from  a  point,  and  are  not  approximately 
parallel  like  the  sun's  rays,  their  shadows  are  necessarily  distorted. 
We  are  all  familiar  with  the  distorted  shadows  thrown  on  the  wall 
by  a  candle.  The  same  distortion  takes  place  in  an  X-ray  picture 
in  a  lesser  degree.  Since  the  rays  proceed  from  a  point,  all  parts 
of  an  object  can  not  stand  in  the  same  relation  to  that  point  and 
the  surface  of  a  plate  at  the  same  time.  The  least  distortion  will 
take  place  when  the  object  is  in  contact  with  the  plate,  and  as  far 
from  the  light  as  is  consistent  with  obtaining  sufficient  effect  to 
take  the  picture :  that  is,  to  have  the  rays  penetrate  the  less  dense 
portions  of  the  object.  Tet  the  distance  from  the  point  to  the 
plate  remain  the  same.     It  follows  that : 

(a)  Shadows  will  be  enlarged  in  proportion  to  the  distance  of 
the  object  from  the  plate,  toward  the  light. 

(b)  Shadows  are  distorted  of  any  object  or  part  of  an  object  not 
in  a  perpendicular  line  from  the  point  of  light  to  the  surface  of  the 
plate,  and  that  distortion  takes  place  in  a  line  drawn  from  the 
base  of  such  perpendicular  through  that  object  or  part  of  an  object. 

As  an  illustration  of  these  distortions,  we  have  represented  in 
figure  890  the  projection  of  a  cubical  block  of  wood  (a).  For  con- 
venience of  drawing,  the  shadow  (b)  is  presented  at  an  angle. 
The  outside  square  of  b  represents  the  upper  surface  of  the  block, 
while  the  inner  square  represents  the  lower.     The  density  of  the 


the;  interpretation  of  skiagraphs 


6oi 


shadow  is  greatest  at  the  edges  of  the  lower  square,  for  they  rep- 
resent the  longest  paths  of  the  rays  through  the  block.  From 
the  consideration  of  figures  891,  892,  893,  and  894  the  reader  will 
readily  observe  that  any  change  in  the  tilt  of  the  plane  of  the  plate 
(Fig.  892,  a),  in  the  shape  or  density  of  the  object,  or  in  the  dis- 
tance of  the  point  of  light  (Fig,  893)  will  produce  a  definite  altera- 
tion of  the  shadow  or  picture.     It  is,  therefore,  necessary  in  looking 


Tf^ts^ 


Fig.  890. 


at  a  skiagraph  to  know  how  the  plane  of  the  plate  lay,  how  far 
distant  the  light  was,  and,  in  general,  what  the  shape  and  density 
of  the  different  parts  of  the  object  were. 

Just  as  it  is  true  that  the  shadow  of  any  object  increases  in  size 
as  it  is  moved  from  the  plate  toward  the  light,  so  also  it  is  true 
that  the  density  of  the  shadow  decreases  as  its  size  increases. 
Each  object  that  is  translucent  to  the  X-rays  seems  to  have  the 
ability  to  cut  off  a  certain  amount  of  X-ray  light.     In  other 


6o2   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

words,  it  contains  a  certain  amount  of  shadow-casting  material. 
As  it  is  moved  from  the  plate  toward  the  light  its  shadow  increases 


A 


I 


\ 


Fig.  891. 


Bale 


TLdte 


TLcU 


^—TlaC* 


Fig.  892. 


in  size,  but  diminishes  in  density,  since  only  a  certain  amount  of 
light  can  be  obstructed  by  that  object. 


THE   INTERPRETATION   OF   SKIAGRAPHS 


603 


Putting  it  in  another  way,  we  see  that  the  object  x  y  (Fig.  891) 
in  the  angle  ah  c  interferes  with  three  times  as  much  Hght  as  if  in 
the  position  oi  ad  e,  but  since  it  can  only  cut  off  a  certain  quantity 
of  rays  in  either  position,  the  shadow  in  d  e  will  be  darker,  though 
smaller  than  b  c.  Of  course,  if  x  y  were  not  penetrated  at  all  by 
the  rays,  the  shadow  would  be  at  a  maximum  in  both  cases.  In 
ab  c  there  are  three  times  as  many  rays  to  go  through,  but  x  y  can 
only  subtract  a  certain  number.  It  can  subtract  that  number 
from  a  d  e  where  there  will  be  a  smaller  remainder  and  hence  a 


Fig.  893. • 


Fig.  894. 


deeper  shadow.  This  is  an  especially  important  point  to  keep  in 
mind,  for  the  range  of  variation  of  density  of  different  bones  is 
very  small,  and  a  very  slight  change  in  position  in  relation  to  the 
plate  may  make  an  enormous  difference  in  the  resulting  picture. 
For  example,  figure  895,  a  skiagraph  of  the  knee  taken  from  be- 
hind,— i.  e.,  with  the  plate  behind, — C  shows  little  or  no  sign  of 
the  patella.  While  with  the  plate  in  front  (B)  and  the  tube  be- 
hind, the  outline  of  the  patella  is  distinguishable  through  the 
shadow  of  the  femur.  This  is  the  more  decided  if  the  tube  is 
brought  quite  near  to  the  back  of  the  knee  (A),  for  then  the  size  of 


6o4   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

the  shadow  of  the  femur  is  increased  and  its  density  diminished, 
while  that  of  the  patella  remains  nearly  the  same  in  both  size  and 
density. 

Another  point  that,  though  simple,  seems  to  cause  misunder- 
standing is  illustrated  in  figure  894,  representing  the  shadow  of  g 
section  of  one  of  the  cylindrical  bones.  It  is  intended  to  show 
why  a  long  bone  appears  like  a  longitudinal  section  in  a  skiagraph. 
Though  the  whole  circumference  may  be  of  the  same  thickness, 
the  rays  that  pass  through  the  sides,  x-y,  meet  more  resistance 


Tiig 


Tuie 


note 


Plait 


Fig.  Sgs. 


than  those  through  the  center ;  hence  the  medullary  cavity  appears 
on  the  plate. 

It  is  often  of  great  assistance  to  plot  out  on  paper  a  projection  of 
the  salient  points  of  the  subject,  as  in  figure  890,  at  the  same  time 
bearing  in  mind  that  variations  occur  in  density  as  well  as  in  size. 
We  should  like  to  go  into  the  question  of  the  deceptiveness  of  skia- 
graphs at  greater  length,  because  we  regard  it  as  of  the  utmost 
importance  that  every  physician  who  uses  this  means  of  diagnosis 
should  fuUy  understand  the  way  in  which  any  conclusion  should  be 
drawn  from  one  of  these  pictures.  Though  the  pictures  themselves 
are  inaccurate  as  pictures  of  the  object,  they  are  accurate  pictures  of 


ITS   PRACTICAL,   VALUE  605 

the  shadows  of  the  different  parts  of  the  object,  and  the  reasoning  of 
conclusions  drawn  from,  them  should  he  exact. 

In  answer  to  the  question  of  what  help  the  X-ray  has  been  in 
increasing  our  knowledge  of  the  pathology  and  treatment  of  frac- 
tures, we  may  mention  first  the  general  points  and  then  the  par- 
ticular fractures  in  which  we  find  it  to  be  of  benefit.  Although 
surgeons  have  always  realized  very  nearly  accurately  the  position 
of  the  displaced  fragments  in  the  common  fractures,  there  can  be 
no  doubt  that  the  production  of  pictures  of  the  exact  condition 
in  individual  cases  gives  more  reliable  information  of  the  condition 
and  relation  of  the  broken  ends  that  can  possibly  be  obtained  by 
palpation.  A  more  definite  knowledge  of  the  pathology  brings 
greater  exactness  of  treatment.  When  the  splints  are  applied,  it 
can  be  ascertained  whether  the  position  is  good  without  removing 
the  bandages.  Little  details  that  otherwise  would  escape  notice 
are  brought  out.  The  patient  is  spared  painful  manipulation  or 
etherization  and  the  bruising  and  laceration  of  the  tissues  from 
unnecessary  handling.  The  question  of  a  cutting  operation  to 
reduce  otherwise  intractable  fragments  may  be  decided  by  an 
exact  knowledge  of  the  positions  of  the  parts.  This  subject  of 
the  advisability  of  interference  by  making  a  simple  fracture 
compound  is  one  that  is  attracting  more  and  more  attention, 
and  will  lead  to  its  being  made  the  rule  in  cases  where  a  good 
result  can  not  be  expected  by  the  simple  method.  When  asepsis 
can  be  practised,  there  is  little  danger  of  making  an  incision,  and 
the  time  saved  in  cases  where  approximation  of  the  fragments  is 
prevented  by  loose  bits  of  bone  or  soft  parts  is  well  worth  this 
slight  risk. 

At  present  we  find  the  X-rays  of  more  assistance  in  the  study  of 
the  pathology  of  fractures  than  we  do  in  their  treatment.  For 
though  we  believe  that  in  each  individual  case  of  fracture  a  skia- 
graph is  of  decided  assistance,  yet  it  must  be  confessed  that  the 
cases  where  it  leads  us  to  modify  the  treatment  to  any  consider- 
able extent  are  few  in  number.  An  exact  diagnosis  of  fracture 
without  skiagraphs  is  always  open  to  doubt,  while  with  a  careful 
X-ray  examination  there  is  seldom  a  doubt.  We  appreciate  the 
X-ray,  too,  when,  after  applying  our  splints,  even  if  plaster,  we 
assure  ourselves  of  the  correct  alinement  of  the  bones. 


6o6      THE   RONTGEN   RAY   AND   ITS   RELATION    TO   FRACTURES 

As  a  means  of  demonstrating  to  students  the  pathology  of  frac- 
tures, a  series  of  lantern-shdes  of  skiagraphs  is  of  the  greatest 
assistance.  The  knowledge  that  the  pictures  are  of  actual  cases 
and  not  theoretic  diagrams  gives  a  practical  interest  that  is  akin 
to  clinical  instruction.  The  plates  when  shown  at  the  same  time 
as  the  case  at  a  hospital  clinic  also  serve  to  illustrate  the  pathology 
and  indications  for  treatment. 

A  not  unimportant  result  of  the  use  of  Rontgen's  discovery  is 
the  exactness  it  offers  as  a  method  of  record  in  the  rarer  fractures. 
Heretofore  statistics  on  the  uncommon  forms  of  fracture  have 
always  been  open  to  the  doubt  of  mistaken  diagnoses,  and  we  have 
been  dependent  on  the  chance  of  securing  postmortem  specimens 
in  order  to  obtain  accuracy.  In  future  the  recorded  cases  of  this 
kind  can  be  illustrated  by  skiagraphs,  and  we  may  look  forward  to 
not  only  greater  accuracy,  but  to  a  much  greater  number  of  cases 
that  were  formerly  considered  rare.  Every  large  hospital  will  be 
able  to  turn  to  its  records  and  say  definitely  in  what  percentage 
any  given  fracture  occurred.  At  the  same  time,  each  individual 
case  has  the  benefit  of  a  definite  record,  and  the  result  can  be  com- 
pared with  the  extent  of  injury. 

The  reader  will  now  ask  in  what  forms  of  fracture  can  we  say  the 
X-ray  is  of  great  assistance.  In  general,  those  bones  that  can  be 
brought  near  the  plate  or  that  are  not  overshadowed  by  other 
bones  give  the  most  satisfactory  skiagraphs.  Therefore,  little  can 
be  expected  of  skiagraphs  of  the  bones  of  the  head  or  vertebrae, 
while  those  of  the  extremities  come  out  with  great  precision.  The 
pelvic  and  shoulder  bones  stand  midway  between  these,  but  with 
a  good  apparatus  and  care  in  the  choice  of  the  relative  positions  of 
the  plate,  tube,  and  the  particular  portion  of  the  bone  to  be  taken, 
we  may  expect  a  definite  picture.  Even  in  the  case  of  the  skull 
and  vertebrae  we  occasionally  find  a  skiagraph  of  advantage.  The 
entire  contour  of  the  lower  jaw  can  be  easily  investigated;  the 
nasal,  alveolar,  and  mastoid  processes  and  malar  bones  come  out 
sharply;  the  cervical  vertebrae,  both  from  behind  and  from  the 
side,  can  be  brought  out  with  great  detail,  while  the  dorsal  and 
lumbar,  though  not  appearing  clearly,  sometimes  show  the  rough 
outlines  of  bodies  and  articular,  transverse,  and  spinous  processes. 
Any  particular  portion  of  any  particular  rib,  except  the  necks,  can 


ITS   PRACTICAL   VALUE 


607 


be  taken  with  great  accuracy;  since  the  plate  can  be  laid  almost 
directly  upon  it.  The  clavicle,  too,  comes  out  clearly.  The  ster- 
num is  too  much  overshadowed  by  the  dense  dorsal  vertebrae  to 
show  definite  outlines. 

Fractures  in  the  shoulder-joint  are  often  impossible  to  recognize 
without  the  X-ray,  particularly  in  those  cases  where  the  swelling 
and  effusion  about  the  joint  prevent  manipulation.  Fractures  of 
the  tuberosities  of  the  humerus,  of  the  surgical  and  anatomical 
necks,  can  be  differentiated  with  great  certainty.  When  separa- 
tion and  dislocation  of  the  epiphysis  have  occurred,  we  may  decide 
the  question  of  operation ;  and  the  same  question  niav  be  answered 
in  those  puzzling  cases  in  which  fracture  of  the  neck  has  occurred 
with  dislocation.  Separation  of  the  tuberosities  we  now  find  is  a 
much  more  common  accident  than  we  had  supposed.  Even  in 
breaks  of  the  shaft  of  the  humerus  and  the  other  long  bones  we 
gain  much  information.  The  extent,  direction,  and  plane  of  cleav- 
age, with  the  exact  amount  of  displacement,  are  guides  for  the 
application  of  padding  and  splints.  It  is  in  fractures  of  the  long 
bones  particularly  that  a  second  series  of  skiagraphs  with  the 
splints  in  position  is  of  value.  The  amount  of  shortening  is 
shown  more  accurately  than  by  measuring  the  landmarks,  for  the 
overlapping  can  be  distinctly  seen.  If  necessary,  the  approxima- 
tion of  the  fragments  can  be  aided  by  proper  pads. 

It  is  not  out  of  place  here  to  refer  again  to  the  question  of  dis- 
tortion, for  in  these  cases  one  must  remember  that  not  only  may 
the  bones  be  magnified,  but  also  the  interspace  between  them. 
Two  or  more  pictures  must  be  taken,  for  a  view  from  the  side  will 
often  show  a  displacement  that  is  not  brought  out  in  the  shadow 
from  in  front  or  behind.  The  fluoroscope  is  particularly  useful  in 
this  sort  of  work,  for,  while  it  does  not  give  the  detail  that  can  be 
seen  in  a  plate,  it  is  clear  enough  to  assure  one  of  the  alinement  of 
the  parts  and  avoids  the  trouble  of  taking  and  developing  the 
plates.  In  general  work,  however,  we  place  less  reliance  on  the 
fluoroscope  than  on  the  skiagraph.  As  will  be  pointed  out  later, 
the  use  of  the  fluoroscope,  also,  is  not  without  danger  of  dermatitis. 

It  is  in  injuries  about  the  elbow-joint  that  we  must  be  more  than 
ever  upon  our  guard  to  avoid  false  conclusions  from  the  distor- 
tions that  we  have  endeavored  to  point  out.     It  will  be  most  use- 


6o8      THE   RONTG^N   RAY  AND  ITS   RELATION  TO   FRACTURES 

ful  to  any  practitioner  who  intends  to  do  X-ray  work  to  take  a 
series  of  skiagraphs  of  the  normal  elbow-joint  from  different  posi- 
tions and  in  different  positions,  and  to  study  most  carefully  the 
projections  of  the  parts  in  each.  Such  a  series  of  injuries  occur  in 
this  region  that  the  diagnoses  are  most  difficult,  and  the  skiagraph 
correctly  interpreted  is  of  the  greatest  help.  Cases  that  formerly 
appeared  in  hospital  records  as  "injury  to  elbow"  are  now  divided 
into  "fractures  of  head  of  radius,"  "neck  of  radius,"  "separation 
of  coronoid  process,"  etc.  A  feature  which  is  now  thoroughly 
brought  out  is  the  common  occurrence  of  fracture  with  disloca- 
tion. Injuries  to  the  elbow  are  particularly  puzzling  in  children, 
since  the  ossification  of  the  epiphyses  is  found  in  different  stages, 
and  the  cartilaginous  portions  do  not  show  in  our  plates.  We 
may  expect  better  results  in  this  field  when,  by  study  and  expe- 
rience, we  learn  more  of  the  time  and  mode  of  formation  of  the 
epiphyses. 

In  the  wrist  Rontgen's  discovery  has  taught  us  much.  We  find 
in  the  fracture  of  the  lower  end  of  the  radius  a  variety  of  types. 
Breaking  of  the  styloid  of  the  ulna  is  found  to  exist  much  more 
often  than  was  supposed.  The  styloid  of  the  ulna  was  fractured 
in  80  per  cent,  of  140  cases  of  Colles'  fracture.  Fracture  of  the 
scaphoid  is  also  not  uncommon  both  alone  and  in  conjunction  with 
Colles'  fracture.  Fractures  of  the  semilunar  and  os  magnum  are 
also  reported.  The  metacarpals  and  phalanges  offer  a  less  inter- 
esting field,  but  in  the  former,  when  impaction  into  the  distal  ex- 
tremity has  occurred  and  it  is  impossible  to  obtain  crepitus  or 
mobility,  a  skiagraph  shows  clearly  the  condition. 

Improvements  in  apparatus  and  technique  have  enabled  us  to 
get,  as  a  rule,  clear  pictures  of  the  upper  extremity  of  the  femur 
when  normal  or  recently  broken.  When  diseased  or  surrounded 
by  much  inflammatory  thickening  or  calcareous  deposit,  the  out- 
lines are  blurred  and  unsatisfactory,  but  yet  throw  light  on  the 
diagnosis.  There  are  often  puzzling  cases  when  fracture,  dis- 
location, tuberculosis,  and  coxa  vara  all  have  to  be  considered,  and 
in  which  a  skiagraph  is  of  the  greatest  assistance.  Any  portion  of 
the  shaft  of  the  femur  can  be  taken,  and,  since  portable  X-ray 
apparatus  have  come  into  use,  the  picture  may  be  obtained  with- 
out disturbing  the  patient  or  his  dressings.     Of  the  knee  we  get 


THE   LOCAL   EFFECT   OF   THE   RONTGEN   RAY  609 

very  clear  plates.  Of  the  method  of  taking  the  patella  we  have 
already  spoken.  We  can  compare  the  results  of  the  traction  treat- 
ment with  those  of  suture  and  wiring.  It  is  of  assistance  in  deter- 
mining whether  the  fragments  are  not  too  much  shattered  to  ad- 
mit of  wiring. 

In  injuries  of  the  lower  leg  we  may  apply  what  has  already  been 
said  of  the  other  long  bones,  and  in  addition  m.ention  a  case  in 
which  a  fragment  from  the  external  malleolus  lodged  back  of  the 
astragalus  under  the  tendo  Achillis.  In  the  foot,  as  in  the  wrist, 
the  X-ray  has  taught  us  much.  Numerous  cases  of  breaks  in  the 
OS  calcis,  astragalus,  and  scaphoid  have  been  reported,  and, 
though  fractures  of  the  other  tarsal  bones  have  not  fallen  within 
our  experience,  their  occurrence  might  easily  be  recognized. 
Gocht  points  out  that  many  swollen  feet  of  uncertain  diagnosis 
prove  to  be  fractures  of  the  metatarsals.  He  also  reports  frac- 
ture of  one  of  the  sesamoid  bones  of  the  great  toe. 

It  is  commonly  said  that  the  X-ray  is  dangerous  to  the  patient 
and  burns  the  skin  and  destroys  the  hair.  This  is  true  as  a  pos- 
sibility, but  nowadays  is  only  to  be  feared  in  connection  with  gross 
ignorance  and  carelessness.  It  is  a  fact  that  Crookes'  tube  in 
action  is  capable  of  causing  an  effect  on  the  tissues  similar  in  many 
respects  to  a  burn.  But  this  action  does  not  take  place  unless  the 
tissues  are  exposed  to  the  tube  for  a  considerable  period  of  time 
and  at  a  very  short  distance.  For  instance,  eight  inches  from  the 
tube  for  an  exposure  of  five  minutes  we  should  consider  perfectly 
safe ;  one  inch  from  the  tube  and  five  minutes,  dangerous.  Dan- 
ger increases  as  we  prolong  the  time  of  exposure  or  diminish  the 
distance  of  the  tube  from  the  skin.  Repeated  exposures  at  short 
intervals  are  approximately  equivalent  in  time  to  one  exposure 
equal  to  the  sum  of  all.  Probably  the  skins  of  different  people 
vary  in  susceptibility  to  this  influence,  but  we  doubt  if  injury  ever 
occurred  unless  the  tube  was  within  a  foot  of  the  patient. 

Danger  to  the  hands  of  the  operator  of  the  apparatus  is  quite 
another  matter,  for  repeated  exposure  may  produce  the  same  con- 
dition. The  most  severe  cases  occur  when,  in  the  use  of  the  fluoro- 
scope,  the  operator  puts  his  hand  near  the  tube,  either  to  hold  the 
patient's  limb  in  place  or  to  demonstrate  the  bones  of  his  hand  to 
an  audience.     Physicians  who  are  called  upon  to  use  the  fluoro- 

.39 


6lO   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

scope  often  should  wear  rubber  gloves  to  protect  the  hands,  or 
cover  the  tube  with  a  grounded  aluminium  screen.  Most  of  the 
recorded  cases  of  severe  injury  took  place  when  the  new  light  was 
first  used,  and  experience  had  not  pointed  out  these  cautions. 
To-da}^,  with  our  improved  apparatus,  the  penetration  and  defi- 
nition render  a  closer  approach  to  the  tube  than  twelve  inches  un- 
necessary. The  cause  of  these  burns  has  been  a  subject  of  much 
discussion,  and  it  may  still  be  considered  an  open  question.  There 
are  many  who  believe  it  to  be  due  to  an  electrostatic  effect,  while 
others,  among  whom  is  Professor  Elihu  Thomson,  affirm  that  the 
Rontgen  rays  themselves  are  responsible.  Professor  Thomson 
certainly  should  be  an  authority  on  this  point,  for  he  has  not  only 
the  advantages  of  his  electrical  knowledge,  but  also  of  experi- 
mental experience.  The  following  is  a  quotation  from  a  personal 
letter  from  him  in  November,  1896,  describing  a  somewhat  heroic 
experiment. 

"Hearing  of  the  effects  of  the  X-rays  on  the  tissues,  especially 
on  the  skin,  I  determined  to  find  out  what  foundation  the  state- 
ments had  by  exposing  a  single  finger  to  the  rays.  I  used  for  this 
the  little  finger  of  the  left  hand,  exposing  it  close  up  to  the  tube, 
about  one  and  one-quarter  inches  from  the  platinum  source  of  the 
rays,  for  one-half  an  hour.  For  about  nine  days  very  little  effect 
was  noticed;  then  the  finger  became  hypersensitive  to  the  touch, 
dark  red,  somewhat  swollen,  stiff ;  and  soon  after,  the  finger  began 
to  blister.  The  blister  started  at  the  maximum  point  of  action  of 
the  rays,  spread  in  all  directions  covering  the  area  exposed,  so  that 
now  the  epidermis  is  nearly  detached  from  the  skin;  underneath 
and  between  the  two  there  is  a  formation  of  purulent  matter  that 
escapes  through  a  crack  in  the  blister.  It  will  be  three  weeks  to- 
day since  the  exposure  was  made,  and  the  healing  process  seems  to 
be  as  slow  as  the  original  coming  on  of  the  trouble." 

Four  days  later:  "The  whole  epidermis  is  off  the  back  of  the 
finger  and  off  the  sides  of  it  also,  while  the  tissue  even  under  the 
nail  is  whitened  and  probably  dead,  ready  to  be  cast  off.  The 
back  of  the  finger  for  a  considerable  extent,  where  it  received  the 
strongest  radiation,  is  raw  and  will  not  recover  its  epidermis,  ap- 
parently, except  from  the  sides  of  the  wound." 

Not  entirely  satisfied  with  this  experiment,  Professor  Thomson 


MEDICOLEGAL   RELATIONS   OF    X-RAYS  6X1 

shortly  afterward  repeated  it  on  another  finger,  which  he  covered 
with  some  aluminium  foil  in  such  a  way  as  to  convince  him  that 
the  tissue,  while  still  exposed  to  the  X-ray,  was  shielded  from  the 
brush  discharge.  As  he  obtained  the  same  result,  he  concluded 
in  favor  of  the  Rontgen  ray  itself.  In  a  recent  article  on  the  sub- 
ject he  shows  that  this  effect  is  due  to  those  of  the  rays  that  are  less 
readily  transmitted  by  the  tissues  and  are  less  valuable  for  skia- 
graphic  purposes. 

This  quotation  is  made  not  only  from  its  value  as  an  experiment, 
but  also  because  it  is  so  clear  a  description  of  this  form  of  derma- 
titis. The  long  period  before  the  effects  become  evident  is  quite 
characteristic,  although  in  many  cases  they  have  appeared  sooner. 
It  seems  probable  that  the  direct  effect  is  on  the  vasomotor  or 
trophic  nerve  supply,  which  eventually  affects  the  nutrition  of 
the  part. 

This  chapter  has  been  mainly  devoted  to  warnings  of  the  dan- 
gers of  the  Rontgen  ray,  and  may  in  a  measure  discourage  prac- 
titioners from  its  use.  It  should  be  stated,  however,  that  when 
the  limits  of  error  are  kept  clearly  in  mind,  the  actual  value  of  the 
discovery  to  surgical  science  is  very  great.  When  there  is  doubt  of 
the  diagnosis  of  a  fracture,  no  physician  has  done  his  full  duty  by 
his  patient  if  he  can  command  skiagraphic  examination  and  has 
not  used  it.  This  is  particularly  true  in  medicolegal  cases  where 
there  is  a  question  of  liability. 


Conclusions  Expressing  the  Views  of  the  American  Sur- 
gical Association  upon  the  Medicolegal  Relations  of 
X-rays;  Adopted  in  May,   1900. 

I .  The  routine  employment  of  the  X-ray  in  cases  of  fracture  is 
not  at  present  (1900)  of  sufficient  definite  advantage  to  justify  the 
teaching  that  it  should  be  used  in  every  case.  If  the  surgeon  is  in 
doubt  as  to  his  diagnosis,  he  should  make  use  of  this  as  of  every 
other  available  means  to  add  to  his  knowledge  of  the  case,  but . 
even  then  he  should  not  forget  the  grave  possibilities  of  misinter- 
pretation. There  is  evidence  that  in  competent  hands  plates  may 
be  made  that  will  fail  to  reveal  the  presence  of  existing  fractures  or 
will  appear  to  show  a  fracture  that  does  not  exist. 


6l2  THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

2.  In  the  regions  of  the  base  of  the  skull,  the  spine,  the  pelvis, 
and  the  hips,  the  X-ray  results  have  not  as  yet  been  thoroughly 
satisfactory,  although  good  skiagraphs  have  been  made  of  lesions 
in  the  last  three  localities.  On  account  of  the  rarity  of  such  skia- 
graphs of  these  parts,  special  caution  should  be  observed,  when 
they  are  affected,  in  basing  upon  X-ray  testimony  any  important 
diagnosis  or  line  of  treatment. 

3.  As  to  questions  of  deformity,  skiagraphs  alone,  without  ex- 
pert surgical  interpretation,  are  generally  useless  and  frequently 
misleading.  The  appearance  of  deformity  may  be  produced  in 
any  normal  bone,  and  existing  deformity  may  be  grossly  exag- 
gerated. 

4.  It  is  not  possible  to  distinguish  after  recent  fractures  between 
cases  in  which  perfectly  satisfactory  callus  has  formed  and  cases 
which  will  go  on  to  nonunion.  Neither  can  fibrous  union  be  dis- 
tinguished from  union  by  callus  in  which  lime-salts  have  not  yet 
been  deposited.  There  is  abundant  evidence  to  show  that  the  use 
of  the  X-ray  in  these  cases  should  be  regarded  as  merely  the  ad- 
junct to  other  surgical  methods,  and  that  its  testimony  is  espe- 
cially fallible. 

5.  The  evidence  as  to  X-ray  burns  seems  to  show  that  in  the 
majority  of  cases  they  are  easily  and  certainly  preventable.  The 
essential  cause  is  still  a  matter  of  dispute.  It  seems  not  unlikely, 
when  the  strange  susceptibilities  due  to  idiosyncrasy  are  remem- 
bered, that  in  a  small  number  of  cases  it  may  make  a  given  in- 
dividual especially  liable  to  this  form  of  injury. 

6.  In  the  recognition  of  foreign  bodies  the  skiagraph  is  of  the 
very  greatest  value ;  in  their  localization  it  has  occasionally  failed. 
The  mistakes  recorded  in  the  former  case  should  easily  have  been 
avoided;  in  the  latter,  they  are  becoming  less  and  less  frequent, 
and  by  the  employment  of  accurate  mathematical  methods  can 
probably  in  time  be  eliminated.  In  the  mean  while,  however,  the 
surgeon  who  bases  an  important  operation  on  the  localization  of  a 
foreign  body  buried  in  the  tissues  should  remember  the  possibility 
of  error  that  still  exists. 

7.  It  has  not  seemed  worth  while  to  attempt  a  review  of  the 
situation  from  the  strictly  legal  standpoint.  It  would  vary  in 
different  States  and  with  different  judges  to  interpret  the  law. 


MEDICOLEGAIv   RELATIONS    OF    X-RAYS  613 

The  evidence  shows,  however,  that  in  many  places  and  under 
many  differing  circumstances  the  skiagraph  will  undoubtedly  be 
a  factor  in  medicolegal  cases. 

8.  The  technicalities  of  its  production,  the  manipulation  of  the 
apparatus,  etc.,  are  already  in  the  hands  of  specialists,  and  with 
that  subject  also  it  has  not  seemed  worth  while  to  deal.  But  it  is 
earnestly  recommended  that  the  surgeon  should  so  familiarize 
himself  with  the  appearance  of  skiagraphs,  with  their  distortions, 
with  the  relative  values  of  their  shadows  and  outlines,  as  to  be 
himself  the  judge  of  their  teachings,  and  not  to  depend  upon  the 
interpretation  of  others,  who  may  lack  the  wide  experience  with 
surgical  injury  and  disease  necessary  for  the  correct  reading  of 
these  pictures. 


CHAPTER    XXI 
THE  EMPLOYMENT  OF  PLASTER-OF-PARIS 

Many  fractures  of  the  upper  and  lower  extremities  may,  at  some 
period,  very  properly  be  treated  by  the  plaster-of- Paris  splint. 

The  plaster-of- Paris  should  be  of  the  best  quality  and  dry. 
Crinoline  is  used  for  bandages.  Commercially  it  is  called  Arrow- 
wanna  Crinoline  Lining.  It  is  a  lining  material  that  is  coarser 
meshed  than  the  cheese-cloth  used  for  gauze  bandages,  and  is  also 
stiffer  than  cheese-cloth.  It  should  be  cut  into  four-yard  lengths, 
folded,  and  stitched  together.  Crinoline  contains  considerable 
sizing  or  glue.  This  is  detrimental  to  its  use  as  a  plaster  bandage. 
It  should,  therefore,  be  washed  of  the  sizing  in  lukewarm  water, 
thoroughly  rinsed,  and  rough  dried.  The  stitching  holds  the 
material  firmly  together  during  the  washing.  It  should  then  be 
cut  into  strips  the  widths  of  the  desired  bandages.  Three  widths 
are  ordinarily  useful — namely,  widths  of  tw^o  inches,  three  inches, 
and  five  and  one-half  inches.  These  four-yard  strips  are  made 
into  roller  bandages.  A  fine-meshed  gauze  bandage  is  being  used 
quite  commonly  in  place  of  crinoline. 

Rolling  the  Plaster. — It  is  a  simple  matter  to  make  one's  own 
plaster  roller  bandages.  It  is  possible  to  purchase  plaster  ban- 
dages in  sealed  packages.  These  are  ordinarily  made  with  un- 
washed crinoline  and  are  less  desirable.  A  shallow  box  or  tray  is 
needed  to  hold  the  plaster.  Two  persons  can  roll  the  bandage 
with  facility.  "A"  manages  the  roll  of  crinoline,  straightens  it  as 
it  unwinds,  spreads  the  plaster  with  a  light  piece  of  board,  the  size 
of  the  hand,  while  "B"  draws  the  crinoline  across  the  tray  from 
under  the  board  held  by  "A,"  and  rolls  up  the  bandage  loosely 
and  evenly.  "A"  with  the  board  held  still  and  plaster  heaped 
upon  the  bandage  behind  it,  regulates,  by  more  or  less  pressure 
upon  the  bandage,  the  amount  of  plaster  distributed  over  the 
crinoline.     It  requires  but  ten  or  fifteen  minutes  to  make  enough 

614 


^i?«»**^'«*«v. 


6is 


6i6 


MAKING   THE    PLASTER    BANDAGE 


617 


bandages  for  a  plaster  splint  for  the  leg  or  thigh.  An  advantage 
in  making  one's  own  bandages  is  that  they  are  made  of  the  desired 
width  and  have  the  proper  amount  of  plaster.  They  are  fresh 
and  more  likely,  therefore,  to  set  readily  upon  being  wet.  If 
many  bandages  are  made  at  a  time  they  may  be  kept  in  a  tin 
cracker  box.     If  the  closed  box  is  put  in  a  dry  place,  these  ban- 


Fig.  901 — Fracture  of  the  elbow  or  forearm.     Application  of  sheet  wadding  for  protection- 
Method  of  holding  the  arm  at  a  right  angle. 


dages  will  keep  indefinitely.  Should  the  plaster  become  damp,  the 
bandages  should  be  placed  in  a  warm  oven  until  dry.  It  is  im- 
portant in  making  the  plaster  rollers  to  put  just  enough  plaster 
into  the  bandage  and  to  distribute  the  plaster  evenly  through  the 
meshes  of  the  crinoline.  The  proper  amount  of  plaster  to  put  into 
a  bandage  can  only  be  learned  by  experience  in  making  and  using 
the  banrlages.      It  is  a  common  error  to  spread  the  plaster  too 


6i8 


THE    EMPLOYMENT   OF    PLASTER-OF-PARIS 


thickly.  The  water  in  which  the  bandages  are  dipped  should  be 
lukewarm  and  of  sufficient  depth  to  cover  the  bandages  when  set 
up  on  end.  The  water  working  its  way  into  the  meshes  of  the 
bandages  displaces  the  air  in  the  bandage,  which  is  indicated  by 
the  bubbles  rising  to  the  surface  of  the  water.  As  soon  as  the 
bubbles  have  stopped  rising  the  plaster  is  thoroughly  wet  through- 
out the  bandage.     Table  salt,  two  teaspoonfuls  to  four  quarts  of 


Fig.  902.  —  Fracture  of  the  elbow  or  forearm.     Application  of  plaster-of-Paris  bandage. 
Method  of  holding  the  arm. 


water,  hastens  the  setting  of  the  plaster.  Its  use,  however,  is  to  be 
deprecated,  because  the  plaster  has  to  be  applied  too  quickly  for 
the  best  results  in  plaster  work,  and  the  brittleness  of  the  plaster 
resulting  from  the  use  of  salt  is  undesirable.  The  plaster  bandage 
should  be  lifted  from  the  water  carefully  with  both  hands  holding 
the  two  ends  so  as  to  retain  as  much  plaster  as  possible  within  the 
roll.     The  bandage  should  then  be  wrung  free  from  water  while 


Fig-  903 — Fracture  of  the  elbow  or  forearm.     Plaster-of-Paris  splint  being  applied. 

at  a  right  angle. 


Elbow 


Fig.  904.  —  Anterior  and  posterior  splints  being  applied  after  having  become  firm  upon  the 
forearm.    For  fracture  of  forearm  bones. 


619 


Fig.  90s.— Anterior  and  posterior  splints  in  position.    To  be  held  in  place  by  adhesive-plastei 
strips  and  a  bandage.    A  light,  durable,  cheap,  efficient  splint. 


Fig.  906. — A  posterior  splint  for  elbow,  forearm,  and  upper  arm.     It  is  most  comfortable. 

620 


Fig.  907. — Posterior  elbow  splint  in  position. 


Fig-  008. —  Poslcri..!  and  anterior  splints  for  elbow.     Anterior  splint  being  applied. 


621 


Fig.  pop. — Anterior  and  posterior  splints  for  the  elbow.     Note  the  additional  plaster  wedge 
being  put  in  place  to  strengthen  the  anterior  splint  at  the  bend  of  the  elbow. 


Fig.  910.— AnteriiT  ami  [njsterior  plaster  splints  applied.     Most  comfortable  and  efficient  in 
injuries  high  up  the  forearm  and  at  the  elbow  and  lower  part  of  upper  arm. 

622 


623 


Fig.  913. — -Lateral  or  side  splint  of  plaster-of-Paris  for  the  foot,  ankle,  and  lower  leg. 
Note  shape  of  crinoline.  The  plaster  cream  is  being  poured  from  pitcher  and  evenly  rubbed 
into  the  layers  of  crinoline. 


Foot  Portion.  Leg  Portion. 

Fig.  914. — Lateral  or  side  splint  of  plaster-of-Paris  ready  for  application  to  leg,  ankle,  and  foot. 
Plaster  cream  has  been  thoroughly  rubbed  into  the  meshes  of  the  crinoline. 

624 


Fig.  915- — Lateral  or  side  splint  of  plaster-of-Paris  applied  to  the  inner  side  of  leg,  ankle, 
and  foot.  Held  in  position  ready  for  bandage.  Note  the  perforated  tin  strip  at  the  ankle 
for  greater  strength.     Foot  at  right  angle  with  leg. 


Fig.   'jiG. — Lateral  or  side  splint  of  plaster-of-Paris.     Retentive  bandage  being  applied, 
reinforcing  strip  seen  at  the  ankle. 


40 


62.i^, 


Fig.  917- — Plaster  gutter  to  posterior  surface  of  leg  and  foot,  held  in  place  by  a  few  turns 
of  a  cheese-cloth  bandage.  This  plaster  posterior  splint  is  made  much  as  is  the  lateral  plaster 
splint  for  the  leg  and  foot. 


Fig.    918.- 


-Anterior  and  posterior  plaster  splints  for  injuries  to  the  leg  below  the  knee  and 
about  the  ankle  and  foot.     Anterior  splint  being  applied. 


626 


Fig.  919.^ — Anterior  and  posterior  leg  splints  applied.     Note  application  of  the  half  cufi  of 
plaster  to  reinforce  the  ankle. 


Fig.  920.- 


-Fracture  of  the  patella.     The  leg  covered  with  sheet  wadding, 
of  the  plaster-of-Paris  roller. 


The  application 


627 


Fig.  921.- 


-Fracture  of  the  patella.     Application  of  the  plaster-of-Paris  roller, 
finished. 


Bandage  being 


Fig.  922. — Fracture  of  the  leg.     Plaster-of-Paris  splint  applied  from  the  toes  to  the  groin. 
Foot  at  a  right  angle  with  the  leg.     Toes  padded  to  prevent  chafing. 


628 


Fig.  923. — Fracture  of  the  leg.     Plaster  cast  of  leg  from  toes  to  below  the  knee  removed. 


Fig.  024 — Fracture  of  the  leg.     Removable  plaster  cast  of  leg.     Same  as  figure  923.     Anterior 
view,  showing  cut  in  plaster. 

6^9 


Fig.  925.— Open  fracture  of  the  leg.     Plaster-of-Paris  splint.     Window  cut  in  plaster,  through 
which  wound  is  dressed.     Window  surrounded  by  oiled  silk. 


Fig.  926. — Open  fracture  of    the  ankle.     Window  in  plaster-of-Paris  splint,  through  which 
wound  is  dressed.     Gauze  seen  in  the  window.     Oiled  silk  about  the  window. 


630 


APPLYING   THE    PLASTER   BANDAGE 


631 


the  hands  still  grasp  its  ends.  The  bandage  should  be  wrung  until 
it  does  not  drip.  In  the  application  of  the  plaster  splint  to  frac- 
tures of  any  part  of  the  body  it  is  important  that  all  deformity 
should  be  corrected  and  that  the  part  should  be  thoroughly  im- 


Fig.  927.— Ham  splint  of  plaster-of-Paris.  The  splint  is  slightly  thicker  at  the  ham 
underneath  the  region  touched  by  the  thumb  in  the  plate.  It  is  thus  strengthened.  More 
comfortable  than  ordinary  wooden  ham  splint. 


This  necessitates  the  presence  of  one  or  two  assist- 


mobilized. 
ants. 

In  applying  a  plaster  splint  with  the  roller  bandage  the  surgeon 
should  do  his  work  so  carefully  that  he  scatters  no  plaster  any- 
where but  upon  the  splint  and  in  the  pail  of  water.  The  surgeon 
should  work  neatly.  The  patient  should  be  protected  by  a  sheet. 
The  floor  should  be  protected  by  a  sheet  spread  under  the  patient 
and  under  the  chair  of  the  surgeon.     The  surgeon  should  remove 


632 


THE   EMPLOYMENT   OF   PLASTER-OF-PARIS 


his  coat,  roll  up  his  sleeves,  and  be  protected  from  unexpected 
spattering  of  plaster  by  an  apron  or  sheet  over  his  body. 

One  thickness  of  sheet  wadding  torn  into  strips,  from  three  to 
five  inches  wide,  and  rolled  into  roller  bandages  and  then  applied 
to  the  limb  forms  the  best  protection  to  the  skin  in  applying  the 
plaster  splint.  The  sheet  wadding  is  purchased  at  any  of  the  dry- 
goods  stores.  It  may  be  purchased  by  the  quarter  bale  or  by  the 
single  sheet.  The  plaster  bandage  should  be  applied  to  the  pro- 
tected part  slowly,  deliberately,  and  accurately.     The  bandage 


Fig.  928. — Fracture  of  the  patella.     Leather  knee-cap  with  hoolcs  for  lacing 
plaster  cast.    Worn  as  a  protection  to  knee  after  fracture. 


Made  irom 


should  be  applied  smoothly,  and  should  have  no  wrinkles  or  thick 
awkward  places  anywhere.  It  is  well  to  rub  the  bandage  as  fast  as 
it  is  laid  upon  the  part  with  the  palm  of  the  hand  slightly  wet  to 
distribute  the  plaster  cream  thoroughly  and  evenly.  Over  bony 
prominences  the  bandage  should  be  very  carefully  molded.  This 
will  insure  a  good  fit  and  less  likelihood  of  slipping  upon  change  of 
position.  It  is  well  to  carry  the  first  roll  of  plaster  as  far  as  it  will 
go,  one  or  two  layers  thick,  completing  the  whole  splint  once,  and 
then  to  go  over  it  again  from  beginning  to  end.  A  sufficient  num- 
ber of  layers  should  be  applied  to  make  a  firm  enough  splint  for  the 


APPLYING   THE    PLASTER    BANDAGE 


633 


support  of  the  part  when  the  plaster  has  set.  The  splint  should 
be  as  light  as  is  compatible  with  strength.  Light  splints,  if  accu- 
rately fitted,  accomplish  more  good  than  heavy,  ill-fitting  ones. 
It  is  better  to  use  too  few  rolls  of  plaster  bandage  rather  than  so 
many  that  a  heavy  and  cumbersome  splint  is  made.  Immediately 
after  the  plaster  has  set,  if  it  is  found  to  be  too  weak  at  any  spot, 
an  additional  bandage  may  be  used  to  reinforce  at  that  point. 
The  part  bandaged  should  be  held  in  perfect  position  until  the 
plaster  has  set  firmly  enough  to  support  it.     This  will  ordinarily 


Fig.  92g — Fracture  of  the  leg.     Removable 
dextrin  splint  with  hooks  and  lacing. 


Fig.  930. — Fracture   of  the  leg.     Same  as 
figure  929.    Anterior  view. 


occur  in  about  ten  or  fifteen  minutes.  The  weight  of  the  splint 
may  be  materially  reduced  by  using  tin  strips  incorporated  in  the 
layers  of  the  plaster  bandage.  These  strips  should  be  perforated 
by  holes  so  as  to  offer  rough  places  to  catch  in  the  plaster  bandage. 
The  two  ends  of  the  splint  should  be  so  finished  that  pressure  and 
consequent  deformity  can  not  occur — for  instance,  the  plaster  of 
the  forearm  should  stop  just  short  of  the  bend  of  the  elbow.  The 
plaster  of  the  thigh  should  be  so  far  below  the  perineum  and  groin 
as  to  permit  of  flexion  of  the  thigh  upon  the  trunk  without  ex- 


634  THE   EMPLOYMENT    OF    PLASTER-OF-PARIS 

coriating  the  skin  of  the  groin.  The  toes  and  fingers  should  be 
left  uncovered  to  admit  of  inspection. 

A  certain  degree  of  skill  is  demanded  upon  the  part  of  the  sur- 
geon for  the  proper  application  of  the  plaster-of- Paris  splint. 
Plaster-of- Paris,  when  used  for  fractured  bones,  is  applied  either 
before  or  after  the  swelling  has  taken  place:  if  applied  before,  it 
constricts  the  seat  of  fracture,  prevents  swelling,  and  may  cause 
great  pain ;  if  applied  after  the  swelling  has  taken  place,  it  becomes 
loose  as  soon  as  the  swelling  of  the  soft  parts  subsides,  and  motion 
of  the  limb  in  the  splint  and  of  the  fragments  of  the  fractured  bone 
one  upon  the  other  is  possible.  It  is  important,  therefore,  to  split 
the  plaster  soon  after  it  has  been  applied,  and  thus  obviate  these 
dangers  of  too  light  and  too  loose  a  splint.  The  tightness  of  the 
splint  should  be  regulated  by  straps  and  a  bandage  of  cheese-cloth. 

The  Removal  of  the  Plaster  Splint. — The  removal  of  the  plaster 
splint  is  difficult.  No  instrument  has  been  devised  that  is  more 
efiicient  than  an  ordinary  sharp  jack-knife.  If  the  plaster  splint 
is  split  immediately  after  its  application, — i.  e.,  as  soon  as  it  is 
hard, — it  will  be  far  easier  than  if  it  is  cut  after  it  is  thoroughly 
dry.  A  strip  of  tin  an  inch  wide  laid  upon  the  protected  leg  and 
covered  by  the  plaster  in  its  application  will  often  be  of  great  ser- 
vice upon  removing  the  plaster.  The  tin  will  serve  as  a  protection 
to  the  skin,  and  the  cutting  may  be  done  more  quickly  and  easily. 

After  removing  most  of  the  plaster  from  his  hands  the  surgeon 
should  wash  his  hands  with  a  little  water  and  granulated  sugar  or 
molasses.  The  sugar  assists  in  removing  all  traces  of  plaster  and 
leaves  the  skin  soft  and  clean.  Bandages  of  plaster-of- Paris  are  so 
readily  obtained,  so  efficient,  so  safe  from  interference  upon  the 
part  of  the  patient,  and  so  easy  to  apply,  that  it  is  surprising  they 
are  not  applied  more  often  than  they  are. 

The  dextrin  bandage  is  much  slower  in  becoming  firm  than  the 
plaster  bandage,  and  yet  is  very  light  and  serviceable.  It  is  ap- 
plied exactly  as  is  the  plaster-of- Paris  bandage.  The  roller  ban- 
dage of  cotton  cloth  is  first  unrolled  and  rerolled  in  a  basin  contain- 
ing a  watery  solution  of  powdered  dextrin.  Formula  for  making 
the  solution  of  dextrin:  Add  about  fourteen  ounces  of  powdered 
dextrin  to  a  pint  of  water,  boil  until  dissolved,  strain,  and  add 
one  ounce  of  alcohol.     The  bandage  is,   therefore,   thoroughly 


the;  dextrin  bandage  635 

saturated  with  the  dextrin  solution.  After  covering  the  part 
bandaged  once,  dextrin  is  painted,  with  a  small  paint-brush,  over 
the  bandage.  This  is  allowed  to  dry  before  a  second  and  a  third 
layer  of  the  bandage  are  applied.  After  each  bandage  a  coating  of 
dextrin  is  appHed.  After  the  final  bandage  several  coatings  of 
dextrin  are  applied,  until  a  shiny,  smooth  surface  results.  This 
bandage  may  be  cut,  and,  by  the  addition  of  strips  of  leather  along 
the  cut  edge  upon  which  are  hooks,  may  be  laced  and  unlaced  as 
necessary  (see  Figs.  929,  930). 


CHAPTER  XXII 
THE  AMBULATORY  TREATMENT  OF  FRACTURES 

By  the  ambulatory  treatment  of  fractures  of  the  lower  extrem- 
ity is  understood  a  method  of  treatment  that  permits  the  im- 
mediate and  continued  use  of  the  injured  limb  as  a  means  of  loco- 
motion. 

Medical  literature  contains  many  references  to  this  method.  It 
has  been  in  use  for  some  ten  years.  It  has  not  met  with  general 
acceptance  even  among  hospital  surgeons.  It  is  a  radical  method 
and  open  to  criticism.  It  contains,  however,  several  important 
suggestions.  It  will  prove  instructive  to  follow  the  adoption  of 
this  method  by  its  advocates,  and  to  discover,  if  possible,  what 
there  is  in  it  of  permanent  value. 

Orthopedic  surgeons  as  early  as  1878  conceived  the  idea  of 
allowing  a  patient  with  a  fracture  of  the  thigh  or  of  the  leg  to  walk 
about  by  means  of  apparatus.  Thomas,  of  Liverpool,  and  Dow- 
browski  used  the  Thomas  knee-splint  in  the  treatment  of  frac- 
tures certainly  as  early  as  the  year  1881  or  1882.  Krause,  a  Ger- 
man surgeon,  published,  in  189 1,  the  first  account  of  the  treatment 
of  fractures  of  the  bones  of  the  leg  in  walking  patients.  Krause 
demonstrated  that  plaster-of- Paris  could  be  used  as  a  splint  in 
fractures  of  the  leg  and  in  transverse  fractures  of  the  thigh. 
Korsch,  in  1894,  presented  a  paper  to  the  German  Surgical  Con- 
gress demonstrating  that  compound  fractures  of  the  leg  and  frac- 
tures of  the  thigh  may  be  treated  with  plaster-of- Paris  splints  and 
early  use.  Korsch  makes  permanent  extension  in  a  thigh  frac- 
ture, while  traction  is  maintained  by  an  assistant,  by  applying  the 
plaster  directly  to  the  skin,  snugly  to  the  malleoli,  the  dorsum  of 
the  foot,  and  the  heel.  A  padded  ring  is  incorporated  into  the 
upper  limit  of  the  plaster  splint  around  the  thigh,  which  presses 
against  the  tuberosity  of  the  ischium,  and  thus  accomplishes  coun- 
terextension.     Korsch's  cases  were  treated  in  Bardeleben's  clinic. 

636 


LITERATURE  637 

Bruns,  of  Tubingen,  in  1893,  described  a  splint  for  use  in  these 
cases  of  fracture  of  the  leg  and  thigh.  Dollinger,  of  Budapest,  in 
1893',  described  a  splint  for  the  ambulatory  treatment  of  fractures 
of  both  bones  of  the  leg,  and  reported  three  cases.  Bollinger's 
method  of  applying  the  plaster-of- Paris  splint  is  the  one  generally 
used  whenever  the  ambulatory  treatment  is  employed.  The 
method  is  described  later. 

Warbasse,  at  the  Methodist  Episcopal  Hospital  of  Brooklyn, 
N.  Y.,  in  1893,  was  the  first  in  this  country  to  adopt  systematically 
Bollinger's  method.  Warbasse  reports  six  cases — all  in  young 
adults.  Bardeleben  reported,  in  1894,  one  hundred  and  sixteen 
cases  treated  with  walking  splints.  There  were  eighty-nine  frac- 
tures of  the  leg,  complicated  and  uncomplicated ;  five  fractures  of 
the  patella;  twenty-two  fractures  of  the  thigh,  five  of  which  were 
compound;  three  cases  of  osteotomy  for  genu  valgum.  Bardele- 
ben lays  down  the  following  law :  "  It  is  of  the  greatest  advantage 
to  the  patient  that  such  a  dressing  can  be  applied  to  the  broken  leg 
that  he  can  bear  the  weight  of  the  body  upon  it  and  walk  about ; 
but  such  a  method  of  treatment  should  be  applied  only  under 
medical  supervision,  and  with  the  most  careful  consideration  of 
complications  that  might  arise."  Korsch  presented  to  the  Ger- 
man Surgical  Congress,  in  1894,  seven  cases — three  of  the  thigh 
and  four  of  the  leg.  Albers,  in  1 894,  reported  seventy-eight  cases 
(fifty-six  of  the  leg,  five  of  the  patella,  sixteen  of  the  thigh,  and  one 
of  the  leg  and  thigh)  treated  by  the  ambulatory  method.  He 
seems  to  be  a  little  more  cautious  than  other  German  surgeons  in 
this  matter.  He  says  that  when  great  pain  is  present,  it  is  best  to 
employ  injections  of  morphin. 

Elevation  of  the  limb  will  often  reduce  the  swelling;  when  this 
does  not  suffice,  the  bandage  must  be  removed.  Severe  local  pain 
from  pressure  indicates  the  necessity  for  cutting  a  fenestrum.  The 
first  attempt  at  walking  should  be  made  on  the  day  following  the 
application  of  the  cast.  A  crutch  and  cane  are  used  at  first ;  later, 
two  canes  are  employed ;  and,  finally,  some  patients  walk  without 
any  support  at  all.  Krause,  in  1 894,  reported  seventy-two  cases 
treated.  He  is  of  the  opinion  that  the  ambulatory  treatment  in 
plaster  splints  must  be  limited  principally  to  fractures  and  osteot- 
omies in  the  region  of  the  malleoli,  the  leg,  and  the  lower  end  of 


638  THE   AMBULATORY    TREATMENT    OE    FRACTURES 

the  thigh.  He  does  not  employ  the  method  in  the  handHng  of 
obHque  fracture  of  the  femur  and  fractures  of  the  neck  of  the 
femur.  Bardeleben  writes  again  in  1 895,  reporting  up  to  that  date 
one  hundred  and  eighty-one  cases  treated  by  the  ambulatory 
treatment.  This  last  report,  of  course,  included  the  one  hundred 
and  sixteen  cases  of  the  previous  record.  Dr.  Edwin  Martin,  be- 
fore the  Surgical  Section  of  the  College  of  Physicians  of  Philadel- 
phia, in  December,  1895,  reported  twenty  cases  of  fracture  of  the 
leg  treated  by  this  method.  Dr.  E.  S.  Pilcher,  of  Brooklyn,  N.  Y., 
in  whose  wards  Warbasse  worked,  reported  to  the  American  Sur- 
gical Association  the  twenty  or  more  cases  treated  by  him  in 
which  the  results  were  satisfactory.  N.  P.  Dandridge,  of  Cincin- 
nati, Ohio,  has  used  the  method  in  eight  cases.  In  most  of  the 
cases  pain  was  complained  of  when  weight  was  borne  on  the  foot. 
In  a  feeble  woman  it  was  necessary  to  remove  the  cast  in  the  third 
week.  In  the  case  of  a  man, — a  compound  fracture  of  the  leg, — 
after  walking  two  weeks  he  had  so  much  pain  that  the  plaster  was 
removed.  Redness  and  swelling  were  great  at  the  seat  of  fracture, 
and  there  was  much  swelling  over  the  internal  malleolus.  Wood- 
bury introduced  the  method  at  Roosevelt  Hospital,  New  York 
city,  and  Fiske  has  reported  cases  treated  at  that  clinic.  Roberts, 
of  Philadelphia,  and  Woolsey,  of  New  York,  have  used  the  method 
in  selected  cases  with  satisfaction.  A.  T.  Cabot,  of  Boston,  has 
used,  in  several  fractures  of  the  femur,  Taylor's  long  hip-splint. 
E.  H.  Bradford,  of  Boston,  has  treated  cases  of  fracture  at  the 
Children's  Hospital  by  a  modified  Thomas  knee  splint,  with  and 
without  plaster-of- Paris  splinting  (Fig.  93i)- 

Those  advocating  the  ambulatory  treatment  suggest  its  appli- 
cation to  fractures  of  the  leg  below  the  knee,  both  simple  and  com- 
pound, and  in  fractures  of  the  lower  end  of  the  femur.  The  appa- 
ratus is  not  to  be  applied  for  three  or  four  days  if  there  is  much 
primary  swelling. 

The  method  of  application  of  the  plaster  splint  in  the  ambu- 
latory treatment  of  fractures  of  the  tibia  and  fibula  alone  is  as 
follows  (this  is  practically  the  method  of  Dollinger) :  First  comes 
the  cleansing  of  the  skin  of  the  leg  with  soap  and  water  and  then 
the  reduction  of  the  fracture.  Then,  with  the  foot  fixed  at  a  right 
angle  to  the  leg,  a  flannel  bandage  is  smoothly  and  evenly  applied 


THE   METHOD    APPLIED   TO    THE    TIBIA  AND    FIBULA  639 

from  the  toes  to  just  above  the  knee.  This  bandage  is  made  to 
include  beneath  the  sole  of  the  foot  a  padding  of  ten  or  fifteen 
layers  of  cotton  wadding,  making  a  pad  about  three-fourths  of  an 
inch  thick,  after  it  is  compressed  by  the  moderate  pressure  of  the 
flannel  bandage.  Over  this  is  now  applied  the  plaster  bandage 
from  the  base  of  the  toes  to  just  above  the  knee,  especial  care  being 


a 


<r. 


Fig.  031.— Thomas  knee  splint  or  ambulatory  treatment  of  leg  fractures,  used  with  a  light 
plaster-of- Paris  leg  splint :  a,  ordinary  form  ;  b,  "  caliper  "  or  convalescent  splint  so  fitted  as 
to  keep  the  heel  of  the  foot  away  from  the  boot  while  the  toes  are  used  ;  c,  the  half-ring 
sometimes  used  at  the  upper  end  ;  d,  lower  end  of  splint,  as  arranged  for  windlass  traction. 


taken  that  the  application  is  made  smoothly  and  somewhat  more 
firmly  than  is  the  custom  in  the  ordinary  plaster  cast.  The  layers 
of  the  bandage  should  be  well  rubbed  as  they  are  applied,  with  a 
view  to  obtaining  the  greatest  amount  of  firmness  with  the  smallest 
amount  of  material.  The  sole  is  strengthened  by  incorporating 
with  the  circular  turns  an  extra  thickness  composed  of  ten  01 


640  the;  ambulatory  treatment  of  fractures 

twelve  layers  of  bandage  well  rubbed  together,  and  extending 
longitudinally  along  the  sole.  The  bandage  is  applied  especially 
firmly  about  the  enlarged  upper  end  of  the  tibia,  and  here  it  is 
made  somewhat  thicker.  As  it  dries  it  may  be  pressed  in  so  as  to 
conform  more  closely  to  the  leg  just  below  the  heads  of  the  tibia 
and  fibula.  The  assistant  who  stands  at  the  foot  of  the  table  and 
supports  the  leg  makes  such  traction  or  pressure  as  is  required  to 
keep  the  fragments  in  proper  position  while  the  plaster  is  being 
applied.  The  operation  requires  about  twenty  minutes,  and  by 
the  time  the  last  bandage  is  applied  the  cast  should  be  fairly 
hard. 

It  is  seen  that  when  this  cast  has  become  hardened  the  leg  is 
suspended.  When  the  patient  steps  upon  the  sole  of  the  plaster 
cast,  the  thickness  of  the  cotton  beneath  the  foot  separates  the 
sole  of  the  foot  so  far  from  the  sole  of  the  cast  that  the  foot  hangs 
suspended  in  its  plaster  shoe.  Thus  the  weight  of  the  body, 
which  would  come  upon  the  foot,  is  borne  by  the  diverging  sur- 
face of  the  leg  above  the  ankle.  The  chief  of  these  is  the  strong 
head  of  the  tibia.  A  lesser  role  is  played  by  the  head  of  the  fibula 
and  the  tapering  calf  in  muscular  subjects. 

In  thigh  fractures  the  use  of  the  long  Taylor  hip-splint,  together 
with  a  high  sole  upon  the  well  foot  and  crutches,  is  generally  ac- 
cepted as  the  best  method  of  ambulatory  treatment. 

The  advantages  claimed  for  the  ambulatory  method  are: 

Time  is  saved  to  the  business  man  b}'  this  method — he  having  to 
give  up  but  about  seven  days  to  a  fracture  of  the  leg.  The  time 
spent  by  the  patient  in  the  hospital  is  less  than  by  other  methods. 
The  general  health  is  conserved;  whereas  by  the  old  method 
the  appetite  is  variable,  sleep  is  troubled,  the  bowels  are  consti- 
pated, and  general  discomfort  prevails.  There  is  greater  general 
comfort  by  this  method  than  by  any  other.  In  drunkards  and 
those  with  a  tendency  to  delirium  tremens  this  liability  is  greatly 
diminished.  In  old  people  the  danger  of  a  hypostatic  pneumonia 
is  lessened.  The  primary  swelling  associated  with  a  fracture  is 
often  avoided,  and  always  less  than  by  the  older  methods.  The 
secondary  edema  and  muscular  weakness  are  less.  The  functional 
usefulness  of  the  whole  leg  is  greater.  There  is  less  atrophy  of 
the  muscles  of  the  thigh  and  leg.     The  amount  of  the  callus  is 


the;  advantages  claimed  for  the  method  641 

diminished.  There  is  less  stiffness  of  neighboring  joints.  Union 
in  a  fracture  occurs  at  an  earher  date. 

Before  this  method  can  be  adopted  generally  and  in  hospital 
treatment  it  must  be  demonstrated  that  it  is  safe,  and  that  it 
offers  chances  of  better  functional  results  than  are  obtained  under 
present  methods,  and  that  the  minor  advantages  claimed  for  it  by 
ardent  German  advocates  are  real  and  not  imaginary.  The  first 
great  advantage  of  the  method  is  stated  to  be  that  the  stay  in  the 
hospital  and  the  time  away  from  one's  occupation  are  much  les- 
sened. Regarding  this  point  the  Massachusetts  General  Hospital 
Surgical  Records  were  consulted  for  these  three  periods:  before 
the  use  of  plaster-of- Paris — that  is,  previous  to  1865;  just  at  the 
beginning  of  the  use  of  plaster-of-Paris  as  a  splint  for  fracture,  and 
in  1895,  1896,  and  1897.  Thirty-five  unselected  cases  of  fracture 
of  the  tibia  and  fibula  were  tabulated  from  each  period.  The 
duration  of  the  average  time  spent  in  the  hospital  in  the  first 
period — i.  e.,  previous  to  1865 — was  fortv-six  days;  in  the  second 
period — i.  e.,  about  1.866 — it  was  forty-five  days;  at  the  present 
time  it  is  sixteen  days.  In  the  second  period  plasters  were  applied 
to  fractured  legs  on  an  average  at  about  the  twenty-eighth  day ;  at 
the  present  time,  on  the  fourteenth  day.  In  other  words,  there 
has  been  since  the  introduction  of  the  plaster  splints  a  gradually 
shorter  detention  in  the  hospital,  as  surgeons  have  come  to  recog- 
nize the  safety  of  an  earlier  application  of  a  fixed  dressing.  On  an 
average,  patients  with  fracture  of  the  leg  are  detained  in  the 
hospital  to-day  but  sixteen  days.  The  very  great  saving  to  the 
hospital  in  time  by  the  ambulatory  treatment  does  not,  therefore, 
appear.  It  is  impossible  to  consider  the  statements  made  with 
regard  to  rapidity  of  healing,  sign  of  callus,  absence  of  muscular 
atrophy,  and  absence  of  rigidity  of  joints,  because  there  are  no 
facts  available  for  the  purpose.  The  advantages  stated  are  based, 
most  of  them,  upon  the  personal  impressions  of  the  surgeon  in 
charge ;  impressions  compared  with  scientific  observations  are  un- 
trustworthy. 

Krause  presents  a  table  from  Paul  Bruns  containing  the  average 

periods  of  healing  in  a  series  of  fractures,  and  compares  these 

periods  with  his  own  fracture  cases  treated  by  the  ambulatory 

method.     This  is  the  only  attempted  scientific  statement  of  obser- 

41 


642  THE    AMBULATORY   TREATMENT   OF    FRACTURES 

vation  on  this  important  point.  Krause  concludes  from  a  stud)f 
of  these  tables  that,  "In  the  treatment  of  fractures  of  the  middle 
and  upper  thirds  of  the  leg,  the  ambulatory  method  shows  a  great 
advantage  in  the  period  of  consolidation  as  well  as  in  the  time 
when  the  patient  can  return  to  work.  It  seems  that  the  higher  up 
the  fracture  is  in  the  leg,  the  sooner  a  cure  is  effected  by  the  am- 
bulatory method  of  treatment." 

Conclusions. — A  review  of  the  literature  does  not  disclose  any 
other  advantage  in  the  results  of  the  ambulatory  treatment  over 
the  present  treatment  of  fractures  of  the  leg  than  that  stated  by 
Krause.  The  present  commonly  accepted  method  of  treating 
fractures  of  the  femur  by  long  rest  in  the  horizontal  position,  with 
extension  by  weight  and  pi^lley,  is  not  satisfactory.  The  pro- 
tracted stay  in  bed  is  undesirable.  The  use  of  the  Taylor  hip- 
splints  in  the  treatment  of  this  fracture,  assisted  by  coaptation 
splints  or  a  splint  of  plaster-of- Paris,  is  of  distinct  value.  This,  how- 
ever, is  a  somewhat  well-known  method  of  ambulatory  treatment. 

Theoretically  and  practically,  the  ambulatory  treatment  does 
not  perfectly  immobilize;  therefore,  it  can  not  preeminently  suc- 
ceed as  a  means  of  treatment.  The  method  in  general  seems  to 
be  unsurgical.  Embolism,  both  of  fat  and  of  blood,  and  the  likeli- 
hood of  pressure- sores  in  the  use  of  the  plaster  splint  are  dangers  to 
be  considered.  It  is  wise  to  allow  the  injured  limb  to  rest  while 
the  reparative  process  is  beginning.  Muscular  relaxation  is  de- 
sirable in  the  treatment  of  fractures.  The  very  admission  by  the 
advocates  of  the  ambulatory  treatment  that  muscular  contrac- 
tions take  place  is  reason  enough  for  supposing  that  complete 
immobilization  is  not  obtained  by  this  method.  However,  in 
certain  carefully  selected  cases  of  fracture  below  the  knee,  par- 
ticularlv  of  the  fibula,  if  under  the  care  of  a  competent  and  skilful 
surgeon,  it  is  possible  to  conceive  of  the  ambulatory  method  being 
used  without  doing  harm. 

A  consideration  of  the  ambulatory  treatment  of  fractures 
should  lead  to  a  more  careful  and  early  use  of  the  plaster-of- Paris 
splint  in  fractures  of  the  leg,  and  to  a  proper  application  of  the 
long  hip-splint  or  its  equivalent  in  fractures  of  the  thigh,  and  to 
the  early  use  of  crutches  and  the  high  sole  on  the  well  foot  in  both 
of  these  lesions. 


materials  for  ordinary  care  of  closed  fractures    643 

Materials  for  the  Ordinary  Care  of  Closed  Fractures 

The  materials  with  which  a  physician  should  be  provided  in 
order  to  properly  care  for  the  fractures  ordinarily  met  with  are 
comparatively  few. 

There  is  scarcely  a  fracture  which  can  not  be  treated  satisfac- 
torily by  the  proper  use  of  plaster-of- Paris. 

Plaster-of- Paris  roller  bandages. 

Washed  crinoline  or  the  common  cheese-cloth  gauze  roller 
bandage. 

Plaster-of- Paris. 

A  jack-knife  for  splitting  plaster  dressings. 

A  pair  of  heavy  scissors. 

Thin  splint  wood,  ^  of  an  inch  in  thickness. 

Iron  wire,  ^  of  an  inch  in  diameter. 

Posterior  wire  splint,  for  adult  leg. 

Anterior  wire  splint,  for  adult  leg. 

Surgeon's  adhesive  plaster. 

Cotton  and  cheese-cloth  roller  bandages. 

Sheet  wadding  for  padding  splints. 


CHAPTER  XXIII 
NOTES  UPON  A  FEW  DISLOCATIONS 

DISLOCATION   OF   THE   CERVICAL  VERTEBRAE 

This  dislocation  may  be  either  bilateral  or  unilateral.     The 

bilateral  form,  in  which  both  the  articular  processes  slip  forward 

or  backward  over  those  below,   is  of  comparatively  infrequent 

occurrence.     It  is  attended  by  marked   symptoms   of  pressure 


Fig.  932. —  Dislocation  of  right  articular  process  ;  head  turns  to  le£t.  Head  also  bent  to 
left  because  process  is  caught.  Left  sternocleidomastoid  relaxed.  Right  sternocleido- 
mastoid tense  and  stretched  (Walton). 


Upon  the  spinal  cord.     A  fatal  termination  is  the  usual  outcome 
of  a  bilateral  dislocation,  although  this  is  not  always  the  case. 

The  most  common  form  of  cervical  dislocation  is  that  occurring 
upon  one  side,  and  is  usually  without  fatal  result.     This  is  rather 

644 


DISLOCATION   OF   THE   CERVICAL   VERTEBRA  645 

a  common  injury.  It  is  often  unrecognized.  In  this  uni- 
lateral dislocation  of  the  cervical  vertebrae  an  articular  process 
slips  over  the  articular  process  below  it  and  either  catches  upon 
the  top  of  the  lower  articular  process  or  slips  down  in  front  of  it. 
This  displacement  causes  the  head  to  tip  over  to  one  side  and 
to  rotate  sidewise.  The  immobility  of  the  head,  the  peculiar 
position  of  the  head,  simulating  a  torticollis;  the  relaxation  of  the 
muscles  of  the  neck — the  contraction  of  which  muscles  would 


Fig.  933. — Right  unilateral  dislocation.     Note  tipping  of  the  head  to  the  left  and  atrophy  of 
the  supraspinatus  and  infraspinatus  muscles  on  the  left  side  (Walton). 


have  produced  the  deformity;  the  taut  condition  of  the  muscles 
upon  the  opposite  side  of  the  neck — these  signs  are  diagnostic  of 
a  dislocation,  of  a  unilateral  dislocation  of  a  cervical  vertebra. 

To  illustrate  definitely :  suppose  that  the  right  articular  process 
slips  forward  and  over  the  corresponding  articular  process  of  the 
vertebrae  below  it  and  has  fallen  into  the  hollow  in  front  of  that 
process.  The  head  will  be  turned  to  the  left  and  will  be  bent 
over  to  the  right,  as  in  figure  935-  The  sternocleidomastoid  will  be 
tense  on  the  left  side  and  lax  on  the  right  side.     Now  suppose,  as 


Fig-  934 — Cervical  vertebras  ;  anterior  surface.     Right  articular  process  of  upper  one  is  di& 
placed  and  caught.     Partial  dislocation.     Clinically  see  figure  P32 


Fig.  935. — Dislocation  of  right  articular  process  ;  ordinary  form,  in  which  the  process  nas 
slipped  way  over ;  head  is  therefore  turned  to  the  left  and  bent  to  the  right ;  the  sternomastoid 
muscle  is  tense  on  the  left,  lax  on  the  right  (Walton). 


646 


Fig.  936 — Complete  unilateral  right  dislocation.     Head  rigid.     Before  operation.     Process 
has  slipped  way  over  (Beach  ;  Walton). 


Fig.  937 — Unilateral  dislocation.     After  operation.     Head  perfectly  flexible  ( Beach  ;  Walton). 


Fig.  938. — Partial  bilateral  cervical  dislocation  ;  anterior  view.     Illustrates  positions  of  bones. 

647 


NOTES    UPON    A   FEW   DISLOCATIONS 


a  second  illustration,  that  there  is  a  dislocation  of  a  right  articular 
process  which  becomes  caught  on  the  top  of  the  articular  process 
below  it  and  does  not  slip  into  the  hollow  in  front.     The  deformity 


Fig.  939. — Same  as  figure  938.   Lateral  view. 


Fig.  940 — Dislocation  forward  of  sixth  cervical  vertebra.     Total  paralysis  below  nipples. 
Death  eighteen  hours  after  the  accident  (Warren  Museum  Specimen). 


will  be  seen  as  in  figure  932.  The  head  will  turn  to  the  left  as  in 
the  complete  dislocation,  but  the  head  will  be  bent  to  the  left 
because  the  process  is  caught  upon  the  top  of  the  one  below. 


DISLOCATION    OF    THE    CERVICAL    VERTEBRA  649 

This  dislocation  is  often  overlooked  because  of  the  absence  of 
serious  symptoms  of  paralysis. 


Fig.  041. — Fracture-dislocation  of  probably  the  fifth  cervical  or  the  sixth.     Photograph  taken 
several  months  after  the  accident.    No  disability  save  that  due  to  position  of  head. 


Fig.  942 — Lateral  view  of  figure  941.     Head  assumed  this  position  immediately  after  a  fall 

dovvn-stairs. 


Fracture  of  an  articular  process  may  occur  together  with  the 
displacement.     This  is  fortunately  rare. 


650 


NOTKS    UPON    A    FEW   DISLOCATIONS 


The  treatment  of  these  cases  should  be  by  what  Dr.  Walton 
has  demonstrated  and  very  properly  called  retrolateral  flexion 
and  rotation  without  extension.  No  amount  of  extension  will 
unlock  the  dislocation.  The  head  is  to  be  bent  laterally  and 
slightly  backward ;  that  is,  abducted  away  from  the  side  displaced. 
This  will  raise  the  articular  process  out  of  the  notch  into  which 
it  has  fallen.  Then  rotation  of  the  displaced  articular  process 
backward  into  position  will  effect  a  reduction.  This,  of  course, 
is  best  done  under  ether  anesthesia.  It  requires  firm,  even 
manipulation,  but  no  very  great  force. 

The  cases  reported  are  too  few  to  determine  how  long  after  a 


Fig.  943. — Diagram  showing  direction  of  tilting  and  rotating  in  reduction  (Walton). 


dislocation  has  occurred  that  this  procedure  will  prove  efficient. 
Several  cases  are  on  record  in  which  spontaneous  reduction  has  oc- 
curred. If  untreated,  some  of  these  cases  recover  from  the  immo- 
bility and  pain,  so  that  the  disability  is  but  slightly  noticeable. 

Dr.  Walton  writes  as  follows:  "This  diagram  (Fig.  943) 
shows  the  upper  surface  of  the  lower  of  the  two  vertebrae 
concerned,  that  is,  the  one  in  normal  position.  The  articular 
processes  of  this  vertebra  are  marked  xx.  The  left  articular 
process  of  the  vertebra  above  having  slipped  into  the  inter- 
vertebral notch  y,  the  situation  of  its  spinous  process  will 
be  indicated  by  the  dotted  lines.  The  direction  in  which  the 
head  must  be  tilted  for  reduction  is  indicated  by  the  line  z  (in 
other  words,  if  the  patient  is  facing  north  the  head  must  be  tilted 


DISLOCATION    OF   THE   JAW  65 1 

southeast) ;  slight  rotation  in  the  direction  of  the  short  curved 
arrow  on  the  right  of  the  diagram  may  be  necessary  to  free  the 
process.  After  the  articular  process  is  freed,  rotation  into  place 
in  the  direction  of  the  long  curved  arrow  on  the  left  of  the  diagram 
will  complete  reduction.  In  case  the  right  articular  process  has  been 
displaced  by  the  dislocation,  these  movements  should  be  reversed." 

In  case  of  bilateral  dislocation  one  process  should  be  freed 
first,  as  in  unilateral  dislocation,  then  the  other.  Ryerson  and 
Walton  have  each  been  able  to  satisfactorily  reduce  by  manipula- 
tion alone  a  dislocation  six  months  after  its  production. 

Precautions. — i.  The  patient  should  be  thoroughly  anesthe- 
tized.    This  proceeding  alone  may  produce  the  desired  result. 

2.  The  patient  should  be  placed  upon  a  chair  for  the  operation 
rather  than  upon  a  table,  for  when  the  patient  is  in  the  sitting 
posture  the  operator  not  only  has  more  freedom  of  movement, 
but  is  also  less  likely  to  become  confused  with  regard  to  the 
movements  of  reduction. 

3.  Extension  not  only  does  not  help  reduction,  but  as  Walton 
suggests  may  perhaps  hinder  it  by  lessening  the  effectiveness  of 
the  fulcrum  furnished  by  the  articular  processes  of  the  uninjured 
side.  This  fulcrum  is  essential  to  the  elevation  of  the  displaced 
process  on  the  other  side.  The  head  should  therefore  be  tilted  or 
rocked  without  traction. 

DISLOCATION  OF  THE  JAW 

The  common  dislocation  is  of  the  inferior  maxilla  forward.  It 
is  ordinarily  a  bilateral  dislocation.  The  condyles  of  the  lower 
jaw  slide  forward  and  over  the  articular  eminence  of  the  temporal 
bone.     There  is  usually  no  rupture  of  the  capsular  ligament. 

The  appearances  of  such  a  dislocation  are  well  shown  in  figures 
946  and  947.  The  mouth  is  open;  the  inferior  maxilla  is  fixed 
and  is  forward  of  its  usual  place;  the  masseter  and  temporal 
muscles  are  stretched  and  taut ;  the  normal  hollow  of  the  glenoid 
cavity  can  be  felt  in  front  of  the  ear — ordinarily  this  is  filled  by 
the  articular  process  of  the  lower  jaw.  If  only  one  side  is  dislo- 
cated, the  chin  will  be  pushed  over  to  the  opposite  side  from  the 
dislocation  and  the  signs  will  be  unilateral. 

Reduction    occasionally    occurs    spontaneously.     In    order    to 


652 


NOTES  UPON   A  FEW    DISLOCATIONS 


effect  reduction  easily,  it  is  necessary  to  relax  the  lateral  ligament 
of  the  joint.  The  manoeuver  of  reduction  is  best  carried  out  with 
the  aid  of  general  anesthesia.     In  order  to  relax  the  lateral  liga- 


Fig.  944.— Note  the  normal  relations  of  the  condyle  to  the  glenoid  ;  the  interarticular  car- 
tilage (after  Helferich). 


945. — Double  dislocation.     Note  open  mouth  ;  displaced  articular  process  ;  empty 
glenoid.      Capsule  uninjured  ;  temporal  muscle  taut  (after  Helferich). 


ment,  the  mouth  should  be  still  further  opened  by  pressure  upon 
the  incisor  teeth;  that  is,  by  depressing  the  chin.  Having  thus 
somewhat  relaxed  the  lateral  ligament,  direct  pressure  backward 
will  effect  a  reduction. 


Fig.  Q46. — Bilateral  anterior  dislocation  of 
the  lower  jaw.  Note  depressed  chin,  rigid  lower 
jaw,  open  mouth,  drawn  cheeks  (Massachusetts 
General  Hospital;. 


Fig.  947. — Lateral  view,  same  case  as  figure 
94&.  Note  rigidity  of  lower  jaw  muscles.  Neck 
held  stifHy  (Massachusetts  General  Hospital). 


Fig.  948. — Dislocation  of  jaw,  right  side  (Perthes). 


653 


654 


NOTES    UPON  A   FEW   DISLOCATIONS 


The  more  common  and  older  method  used  for  reducing  this 
dislocation  is  by  pressing  down  upon  the  molar  teeth  and  lifting 
and  pressing  back  the  chin.  This  method  is  usually  not  so  satis- 
factory as  is  that  first  described. 

Recurring  dislocations  can  be  successfully  treated  by  open 
incision  and  suturing  the  meniscus  to  the  periosteum  of  the  bone. 


949-— Fracture  of  the  inferior  maxilla  mistaken  for  a  unilateral  dislocation, 
deviation  of  the  chin  to  the  left  side. 


Note 


Simple  immobilization  of  a  reduced  dislocation  for  a  period  of  a 
few  weeks  will  often  prevent  recurrence  of  the  difficulty. 

Old  irreducible  dislocations  may  require  resection  of  the  con- 
dyles of  the  lower  jaw,  or  it  may  be  possible  to  reduce  the  dislo- 
cation by  the  method  of  McGraw.  McGraw's  method  consists 
in  making  a  tiny  incision  through  the  skin  over  the  neck  of  the 
inferior  maxilla  and  inserting  through  it  a  steel  hook,  which  is 
usually  so  bent  as  to  fit  accurately  the  neck  of  the  jaw.  Traction 
upon  this  hook  will  sometimes  reduce  the  dislocation. 


DISLOCATION  OF  THE  CLAVICLE 


Fig.  9SO. — Dislocation  of  the  acromioclavicular  joint.  X-ray  appearance  of  a  case  before  opera- 
tion. I.  clavicle  ;  2,  coracoid  process  ;  3,  acromion  process  ;  4,  head  of  humerus  ;  s,  glenoid  cavity 
of  the  scapula  ;  6,  spine  of  the  scapula.  The  upper  arrow  points  to  the  acromioclavicular  joint.  The 
lower  arrow  points  to  the  periosteum  stripped  off  of  the  under  surface  of  the  clavicle. 


^ 


Fig.  OST.^ — Dislocation  of  the  acromioclavicular  joint.  X-ray  appearances  after  operation. 
Same  case  as  the  7)receding.  Explanation  of  figures  same  as  in  previous  illustration.  Upper  arrow 
points  to  the  now  normal  relations  of  the  acromioclavicular  joint. 

655 


Fig.  952. — View  of  the  acromioclavicular  joint  on  frontal  section  from  in  front.  AB.  The 
acromioclavicular  joint.  Note  the  superior  and  inferior  ligaments  forming  the  capsular  ligament. 
Note  the  interarticular  fibrocartilage.  A'B'.  Dislocation  of  the  joint,  rupture  of  interarticular  liga- 
ment. Note  especially  the  superior  ligament  stripped  off  the  acromion  and  the  inferior  ligament 
stripped  off  the  clavicle. 


Fig.  QS3' — View  of  the  acromioclavicular  joint  from  above.     To  illustrate  a  suture  passed  through 
transverse  drill  holes  in  the  acromion  A  and  clavicle  B. 


656 


CLAVICLE 


ACR.Oin(D 


COTIKCOVD 


J 


Fig.  954. — View  from  in  front,  looking  at  the  right  shoulder.  Diagram  representing  a  complete 
dislocation  of  the  acromioclavicular  joint.  Note  the  stretching  of  the  acromioclavicular  joint  cap- 
sule, the  torn  coracoclavicular  ligament.  Note  the  sutures  passed  through  the  capsule  and  clavicle  to 
the  coraco-acromial  ligament. 


Outer 
end  of 


Fig.  955. — Acromioclavicular  dislocation.  Dislocation  of  the  outer  end  of  left  clavicle 
upward.  Complete  form.  Disability  of  upper  arm,  certain  movements  painful.  Treatment  of 
this  dislocation  is  often  successful  by  pressure  applied  after  reduction,  as  shown  under  frac- 
ture of  clavicle.  Open  incision  and  suture  are  indicated  if  reduction  is  impossible  and  dis- 
ability exists. 


42 


657 


658 


NOTES    UPON    A    FEW    DISLOCATIONS 


Outer  end  of  clavicle. 


Fig.  956. — Upward  dislocation  of  the  clavicle  at  the  left  acromioclavicular  joints 


DISLOCATION  OF  THE  ACROMIOCLAVICULAR  JOINT 
A  dislocation  of  the  acromioclavicular  joint  usually  means 
that  the  outer  end  of  the  clavicle  is  displaced  upward  and  slightly 
outward.  This  dislocation  is  not  very  uncommon.  It  occasions 
varying  degrees  of  deformity  and  certain  disabling  symptoms 
may  be  produced  by  it.  Ordinarily  it  is  a  dislocation  which  is 
readily  treated  by  pads  and  simple  retentive  apparatus.  At 
times,  however,  it  is  impossible  either  to  reduce  the  dislocation 
completely  or  to  hold  it  reduced.  Occasionally  the  deformity  is 
so  great  as  to  be  very  noticeable. 

It  seems  probable  from  the  observation  and  experience  of 
Krecke,  Poirier,  Rieffel  and  Sheldon,  i,  that  the  acromioclavicular 
ligaments  are  torn  in  all  cases;  2,  that  the  conoid  Hgament  is 
sometimes  torn  in  incomplete  dislocations;  3,  that  the  conoid 
ligament  is  always  torn  in  complete  cases;  4,  that  the  conoid  and 
trapezoid  ligaments  are  usually  torn  in  the  complete  cases. 

A  male,  aged  24  (see  X-rays),  Figs.  95o-954>  after  having  had  a  fall 
from  a  ladder  in  the  gymnasium,  presented  a  dislocation  of  the  left 
acromioclavicular  joint.      The  dislocation  persisted  despite  the  usual 


DISLOCATIONS    OF    THE    ACROMIOCLAVICULAR    JOINT       659 

treatment  with  pads,  adhesive  plaster  and  bandages.  The  dislocation 
was  only  partially  reducible.  The  deformity  was  marked.  There 
was  about  three-fourths  of  an  inch  separation  between  the  clavicle  and 
the  acromion;  that  is,  between  the  articular  surfaces.  There  was  no 
especial  loss  of  function. 

Operation  was  sought  because  of  the  deformity.  About  six  weeks 
after  the  accident  a  suture  of  the  acromioclavicular  joint  was  made.  The 
material  used  was  linen  and  catgut.  The  patient  was  kept  in  bed  on 
his  back  for  ten  days  following  the  operation.  The  result  was  perfect. 
There  remained  no  deformity  and  the  movement  and  usefulness  of 
the  joint  was  restored. 

The  indications  for  operative  interference  are  irreducibility 
and  a  failure  to  maintain  reduction.  The  dislocation  is  irre- 
ducible because  of  the  interposition  of  the  torn  capsule  or  of  the' 
ruptured  trapezius  muscle.  The  maintenance  of  reduction  is 
impossible,  because  of  the  rupture  of  the  coracoclavicular  ligaments. 
At  operation,  therefore,  the  indications  are  to  remove  any  inter- 
posed parts  and  so  to  suture  the  torn  ligaments  as  to  restore  the 
relation  of  the  parts  to  their  normal  condition. 

I  would  formulate  the  treatment  of  a  specific  case  somewhat  as 
follows:  If  the  dislocation  is  one  of  moderate  degree,  it  should  be 
treated  by  simple  retentive  apparatus.  If  the  dislocation  is 
extreme,  in  which  case  it  is  probable  that  the  coracoclavicular 
ligaments  are  torn,  a  suture  of  the  parts  is  indicated.  If  the 
retentive  apparatus  does  not  hold  cases  of  the  first  class,  then 
suture  should  be  employed. 

Various  methods  of  suture  have  been  used  ;  by  wire,  by  silk 
and  by  absorbable  material.  Different  forms  of  pin  have  been 
employed.  The  method  of  placing  the  suture  seems  to  be  of 
some  importance. 

In  order  to  secure  a  firm  hold  on  the  outer  end  of  the  clavicle 
a  suture  should  be  placed  so  as  to  make  traction  on  the  clavicle 
from  below  in  the  direction  of  the  coracoacromial  ligament.  The 
suture  should  be  passed  through  the  clavicle  and  the  coraco- 
acromial ligament. 

The  treatment  of  this  dislocation  with  the  patient  on  the  back, 
whether  with  or  without  operation,  will,  of  course,  remove  the 
weight  of  the  upper  extremity  and  so  assist  very  materially  in 
the  proper  healing  of  the  parts. 


Fig.  057. — Dislocation  of  the  inner  end  of  the  clavicle.     Note  the  arrow  points  to  the  left  sterno- 
clavicular joint.     Note  the  tense  left  sternocleidomastoid  muscle. 


H 


Fig.  9s8. — Subcoracoid  dislocation  of  the  humerus.  H,  Head  of  humerus  ;  G,  glenoid  ;  Co, 
coracoid  ;  C,  clavicle  ;  A,  acromion  ;  R,  ribs.  Note  the  position  of  the  head  of  the  humerus  with 
.relation  to  the  glenoid  cavity.     Note  the  axis  of  the  humerus. 


660 


DISLOCATION    OF    THE;    SHOULDER 


66 1 


DISLOCATION  OF  THE  SHOULDER 

The  head  of  the  humerus,  through  extreme  abduction  of  the 
arm,  leaves  the  capsule  of  the  shoulder-joint  at  its  lowest  point. 
The  upper  end  of  the  humerus  rests  beneath  the  coracoid  process 
in  the  common  form  of  dislocation  of  the  shoulder. 

The  signs  of  a  subcoracoid  dislocation  are  partly  illustrated  in 
the  chapter  on  Fracture  of  Humerus.   The  direction  of  the  long  axis 


Fig.  959 — X-ray  of  a  subcoracoid  dislocation  of  the  humerus.  Note  the  position  of  the 
humeral  head,  with  reference  to  acromion,  coracoid,  clavicle,  and  glenoid  cavity.  (X-ray 
taken  by  Mr.  Dodd,  Massachusetts  General  Hospital. 


of  the  upper  arm  is  changed  from  the  normal.  The  arm  is  per- 
manently abducted  from  the  body.  Voluntary  movements  of  the 
shoulder  are  more  or  less  restricted.  The  shoulder  is  flattened  be- 
cause the  head  of  the  humerus  is  absent  from  its  normal  position. 
The  head  of  the  bone  is  felt  in  its  new  position  under  the  coracoid 
process.  The  head  of  the  bone  may  be  fairly  easily  felt  by  pal- 
pating the  axilla.  The  elbow  cannot  be  brought  readily  to  the  side. 
Before  any  attempt  is  made  at  reducing  the  dislocation  it  is 
wise  to  determine  so  far  as  possible,  by  careful  examination  and 


Fig.  960. — Subcoracoid  dislocation  of  the  left  shoulder.  Note  change  in  axis  of  humerus. 
Note  method  of  palpating  under  acromion,  demonstrating  hollow  on  the  left  due  to  absence  of 
head  of  bone  from  the  glenoid  cavity.  ^ 


Fig.  g6r.— Dislocation  of  the  humerus.     Note  muscles  of  shoulder,  flattened  deltoid, 
position  of  the  head  of  the  humerus  (after  Helferich). 

662 


Note 


DISLOCATION    OI^    THE)    SHOULDER  663 

by  the  assistance  of  the  X-ray,  whether  or  not  a  fracture  of  the 
anatomical  or  surgical  neck  or  the  tuberosity  of  the  humerus  or 
of  the  glenoid  cavity  of  the  scapula  has  occurred,  complicating 
the  dislocation.     Obviously,  if  a  fracture  exists  associated  with 


Fig.  962. — Reduction  of  subcoracoid  dislocation  of  the  shoulder.  First  position  (see  Fig. 
063) ;  Elbow  at  side,  forearm  rotated  outward.  Note  fulness  (head  of  humerus)  beneath  cora- 
coid  process  (rii)  ;  absence  of  head  of  humerus  under  acromion  (/)  ;  relaxed  muscles  {g,  h,j). 
a.  Deltoid  ;  b,  pectoralis  major  ;  c,  pectoralis  minor ;  d,  coracobrachialis  ;  e,  biceps,  two  heads ; 
y,  triceps;  g,  supraspiiiatus ;  h,  infraspinatus;  /,  subscapularis  ;  k,  humerus;  /,  acromion 
process ;  m,  coracoid  process  ;  w,  coracoacromial  ligament. 


a  dislocation,  it  will  most  likely  be  impossible  to  effect  the  reduc- 
tion by  manipulation. 

The  older  method  of  reduction  is  still  often  useful.     By  the 
older  method  traction  is  made  upon  the  humerus,  which  is  grasped 


664 


NOTSS    UPON    A    FEW    DISLOCATIONS 


at  the  elbow,  with  the  arm  raised  to  a  right  angle  with  the  body. 
Countertraction  is  made  by  steadying  the  trunk  by  means  of  a 
folded  sheet  around  the  chest.  While  traction  is  being  made, 
the  arm  is  gradually  brought  to  the  side.  A  third  assistant 
manipulates  by  pressure  the  head  of  the  bone  while  the  traction 
is  being  made. 

The  best  method  for  the  reduction  of  the  common  subcoracoid 
shoulder  dislocation  is  that  known  as  Kocher's  method.  It  con- 
sists of  the  following  procedures : 


Fig.  963. — Reducing  dislocation  of  the  shoulder.  Note  shoulder  over  edge  of  table; 
patient  on  back.  First  step :  Elbow  at  side.  Note  method  of  grasping  above  elbow  and 
wrist. 


1.  With  the  patient  lying  upon  the  back,  the  surgeon,  standing 
upon  the  side  of  the  dislocated  shoulder,  grasps  with  one  hand  the 
dislocated  humerus  above  the  condyles,  and  with  the  other  hand 
the  wrist  of  the  patient.  The  forearm  of  the  patient  is  flexed  at 
a  right  angle.  The  elbow  is  carried  well  to  the  side  of  the  body. 
See  figures  962  and  963. 

2.  See  figures  964  and  965.  The  humerus  is  rotated  upon  its 
long  axis,  carrying  the  forearm  outward,  external  rotation.  This 
movement  is  an  important  one,  as  by  it  the  opening  in  the  capsule 


DISLOCATION    OF    THE    SHOULDER 


665 


through  which  the  head  of  the  bone  left  the  joint  is  relaxed  and 
made  patent. 

3.  See  figures  966  and  967.  With  the  humerus  thus  rotated 
strongly  outward,  the  elbow  is  strongly  adducted  just  across  the 
median  line  of  the  body. 


Fig.  964. — Reduction  of  subcoracoid  dislocation  of  the  shoulder.  Second  position  (see 
Fig.  849) :  Forearm  held  rotated  outward.  Elbow  advanced  across  the  thorax  to  near  median 
line.     Traction  downward  in  line  of  long  axis  of  humerus.     (Lettering  same  as  in  Fig.    962.) 


4.  See  figures  968  and  969.  When  the  elbow  is  brought  well 
to  the  median  line  in  adduction,  the  hand  is  placed  upon  the 
opposite  shoulder,  thus  rotating  the  humerus  inward. 

Throughout  these  four  procedures  good  steady  traction  is  main- 
tained by  the  surgeon,  downward  in  the  direction  of  the  long  axis 
of  the  humerus.     This  method  of  Kocher  may  be  used  without 


666 


NOTES    UPON    A    FEW    DISLOCATIONS 


ether,  or  with  the  aid  of  an  anesthetic.  In  the  great  majority  of 
dislocations  this  method  will  prove  efficient. 

Recurrent  Dislocations  of  the  Shoulder. — These,  if  frequent 
and  troublesome,  may  be  prevented  by  incision  and  by  taking  a 
tuck,  by  means  of  suture,  in  the  capsule.  The  anterior  incision 
in  the  sulcus,  between  the  deltoid  and  pectoralis  major  muscles, 
IS  the  better  method  of  approach  to  the  joint  capsule. 

Old  Unreduced  Dislocations. — It  is  not  known  what  the  limit 
of  time  may  be  within  which  it  is  wise  and  proper  to  undertake 
the  reduction  of  an  old  unreduced  dislocation  uncomplicated  by 
any  fracture.  Each  individual  case  must  be  judged  upon  its 
own  merits.  Suffice  it  to  say  that  several  weeks  may  have  elapsed 
and  yet  a  dislocation  may  be  reduced  by  manipulation.     The 


Fig.  965. — Second  step  :  Elbow  at  side.    Rotation  of  forearm  outward  to  the  extreme  limit  of 

rotation. 

dangers  of  attempting  reduction  after  several  weeks  are  injury  to 
important  vessels  and  nerves  and  fracture  of  the  humerus. 

When  moderate  manipulation  has  been  undertaken  and 
failed,  operation  is  indicated.  If  there  is  no  fracture  of  the 
upper  end  of  the  humerus  associated  with  the  dislocation,  it 
may  be  possible,  by  the  assistance  of  the  Porter  and  McBurney 
hook,  to  effect  a  reduction  through  an  open  incision.  Usually, 
when  a  fracture  is  associated  with  a  dislocation,  and  manipula- 
tion and  operation  with  the  aid  of  the  hook  are  not  of  avail,  an 
excision  of  the  head  of  the  bone  becomes  necessary.     This  opera- 


DISLOCATION    OF    THE    SHOULDER  667 

tion  is  attended  with  some  risk,  and  yet  useful  arms  are  secured 
by  this  means. 

The  treatment  after  reduction  of  simple  dislocations  of  the 
shoulder  is  important.  After  having  reduced  a  dislocation  it  is 
necessary  to  partially  immobilize  the  shoulder-joint.  This  can 
best  be  accomplished  by  a  swathe  about  the  body,  enclosing  the 


Fig.  g66. — Reduction  of  subcoracoid  dislocation  of  the  humerus.  Third  position  (see  Fig. 
851):  Elbow  held  at  midpoint  of  thorax,  traction  downward  on  humerus  maintained.  Rota- 
tion of  humerus  being  made  upon  its  long  axis  by  carrying  hand  to  shoulder.  Note  reduc- 
tion of  the  dislocation.  The  head  lies  under  the  acromion  (/)  within  the  capsule  of  the 
shoulder-joint  upoh  the  glenoid  cavity  of  the  scapula.     (Lettering  same  as  in  Fig.  962.) 

upper  arm,  and  a  cravat  sling  around  the  neck  and  wrist.  The 
body  swathe  may  be  used  only  at  night.  During  the  daytime 
the  arm  may  wear  the  sleeves  of  shirt  and  coat  and  the  wrist  be 
supported  by  a  simple  cravat  sHng.  Ordinarily  it  is  customary 
to  immobilize  the  reduced  shoulder  for  many  weeks  without  giving 
it  any  passive  motion.  It  is  my  experience  that  poor  results 
follow  such  treatment.     It  is  far  wiser  and  safer  to  make  gentle 


668 


NOTBS    UPON    A    FEW    DISLOCATIONS 


passive  motion  upon  the  first  day  after  the  reduction  and  to  con- 
tinue these  gentle  movements  with  increasing  force  and  exertion 
each  succeeding  day,  until  at  the  end  of  a  week  or  a  week  and  a 
half  the  patient  is  no  longer  restrained  in  his  movements,  but  is 
encouraged  to  make  all  movements  that  are  natural. 


Fig.  967. — Third  step  :  While  external  rotation  is  maintained  traction  downward  is  made  and 
at  the  same  lime  the  elbow  is  carried  in  adduction  to  the  mid-line  of  body. 


UNREDUCED  DISLOCATIONS  OF  THE  SHOULDER 

Causes  of  Irreducihility. — A  fracture  of  the  anatomical  or  sur- 
gical neck  of  the  humerus  ;  a  fracture  of  the  greater  tuberosity, 
which  may  lie  in  the  joint  ;  the  long  biceps'  tendon  may  be  dis- 
placed either  so  as  to  hold  the  head  of  the  bone  from  returning  to 
the  glenoid,  or  the  tendon  may  slip  between  the  head  and  the 


Fig.  968.— Reduction  of  subcoracoid  dislocation  of  the  humerus  completed.  Fourth  post 
tion  (see  Fig.  853).  Note  head  of  bone  under  the  acromion  (/)  to  the  outer  side  of  coracoid 
process  (vi)  and  undisturbed  normal  anatomical  relations.     (Lettering  same  as  in  Fig.  562-) 


Hr.  <)(»).— Fourth  step;  While  traction  is  being  made,  rotation  inward  is  made  of  the  arm  by 

placing  hand  upon  opposite  shoulder. 

669 


670  NOTES    UPON    A    FEW    DISLOCATIONS 

glenoid  ;  the  capsule  may  be  stretched  over  and  be  adherent  to 
the  glenoid  cavity  ;  the  capsule  may  become  ossified  ;  the  glenoid 
may  become  filled  up  with  new  fibrous  tissue  or  bone  ;  a  fracture 
of  the  glenoid  cavity  of  the  scapula.  Any  or  several  of  these 
causes  of  irreducibiHty  may  be  present  in  a  given  case.  An 
X-ray  may  determine  immediately  the  difficulty. 

If  the  X-ray  discloses  an  insurmountable  obstacle  to  reduction 
manipulative  attempts  should  be  discontinued  at  once,  for  only 
harm  can  result  to  already  damaged  tissues.  In  the  absence  of 
fracture  of  the  humerus  or  glenoid  (conditions  which  the  X-ray 
will  reveal)  bloodless  or  non-operative  measures  should  be  care- 
fully tried  to  reduce  the  dislocated  head. 

Method  of  Attempting  Reduction  of  an  Old  Dislocation  of  the 
Shotilder.— Complete  anesthesia  is  necessary.  The  patient  should 
be  placed  with  the  injured  shoulder  close  to  the  edge  of  the  table. 
The  adhesions  (periarticular)  should  be  gently  and  progressively 
broken  by  attempting  to  perform  all  the  normal  movements  of 
the  shoulder  joint  in  sequence  (forward  and  backward  swing, 
abduction,  adduction  rotation,  circumduction).  Having  broken 
all  adhesions  an  attempt  by  a  familiar  method  should  be  made 
to  reduce  the  dislocated  head. 

Before  deciding  to  operate  in  a  given  case  the  question  must 
be  settled  as  to  whether  the  disability  without  operation  is  any 
greater,  in  the  absence  of  pain  and  pressure  symptoms,  than  the 
disability  following  operation.  The  whole  case  must  be  con- 
sidered from  the  point  of  view  of  the  individual's  age,  sex,  health, 
occupation,  temperament,  etc.  Certain  cases  after  operation 
have  so  great  a  hmitation  of  motion  that  the  arm  is  of  httle  use. 
Certain  other  cases  without  any  operation  have  fairly  useful 
arms.     Each  individual  case  must  be  decided  upon  its  merits. 

Operative  Procedures  for  Irreducible  Dislocation  of  the  Humeral 
Head. — ^i.  If  no  fracture  exists,  (a)  Exposure  of  the  joint,  removal 
of  adventitious  tissues,  reduction  of  the  head  by  traction  or 
pressure,  (h)  Removal  of  a  portion  of  the  head  of  the  bone, 
placing  upper  end  of  shaft  near  glenoid,  (c)  Complete  excision 
of  the  head  of  the  bone. 

2.  If  a  fracture  exists,  (a)  An  attempt  should  be  made  to 
replace  the  head  in  the  glenoid  cavity  and  then  to  unite  the 


unre;duce;d  dislocations  of  the;  shoulder 


671 


fractured  bone  fragments.  If  this  is  impossible  then  (&)  an 
excision  of  the  proximal  fragment  should  be  done.  If  there  are 
reasons  why  it  is  wise  to  postpone  operation  in  an  acute  case, 
resection  may  be  later  considered,  if  pain  and  too  great  disability 
supervene,  and  demand  a  secondary  operation.  One  should  not 
operate  in    those  old  and  enfeebled  individuals  debilitated  in  all 


Fig.  970. — Stimson's  method  of  rcciuctibii  of  an  nnterior  dislocation  of  the  right  shoulder- 
joint.  Note  patient  on  right  side.  Hand  and  arm  hanging  through  a  slit  in  canvas  stretcher 
at  right  angles  to  the  long  axis  of  the  body.  Note  weight  attached  to  right  wrist.  The 
assumption  of  this  position  usually  results  in  the  head  of  the  humerus  slipping  into  place 
without  the  use  of  an  anesthetic  (Stimson). 


their  tissues.  The  anterior  incision,  approaching  the  capsule 
through  the  interspace  between  the  deltoid  and  pectoralis  major 
muscles,  is  the  most  satisfactory  of  all  the  incisions 

End  Results  after  Excision  of  the  Shoulder  for  Dislocation  Frac- 
ture.— After  excising  the  head  of  the  humerus,  rotation  at  the 
shoulder  will  be  impaired  and  abduction  will  be  much  lessened. 
Forward  and  backward  swing  will  be  nearly  normal,  adduction 


672  NOTES    UPON    A    FEW    DISLOCATIONS 

Humerus.  Radius. 


Olecranon. 

Fig.  971 — Dislocation  of  both  bones  of  the  forearm  backward  (X-ray,  Massachusetts  Genera] 

Hospital). 


Fig.  972. — Showing  a  method  of  reduction  of  a  dislocation  of  the  elbow  backward.  Note 
partial  extension  of  forearm  on  arm  ;  position  of  thumbs  of  surgeon  behind  olecranon  making 
pressure  forward  while  fingers  make  pressure  backward. 

will  be  normal.  The  power  of  the  forearm  will  be  maintained. 
The  disability  following  excision  is  very  largely  due  to  inability 
to  abduct  the  arm  from  the  side.     It  is  often  impossible  to  touch 


DISLOCATION    OP   THE    ELBOW 


673 


unaided  the  top  of  the  head  with  the  hand  of  the  operated  side. 
The  atrophy  of  the  whole  group  of  shoulder  muscles  is  marked. 
See  pp.  188  to  195  for  details  of  the  results  following  excisions 
of  the  shoulder-joint. 


Fig-  973- — Dislocation  of  both  radius  and  ulna  backward.     Note  the  olecranon  epiphysis. 


DISLOCATION  OF  THE  ELBOW 

The  usual  form  of  displacement  is  of  both  bones  of  the  forearm 
backward.     The  normal  relation  of  the  three  bony  points  of  the 


Ulna 


Fig.  974. — Dislocation  of  the  radius 


Humerus 


Note  the  position  of   the  radial  head  and  the  external 
condyle. 


elbow  is  not  maintained  (see  Elbow  Fractures),  The  olecranon  is 
felt  to  be  posterior  to  the  two  condyles.  There  is  a  shortening  of 
the  forearm.     Lateral  mobility  at  the  elbow  exists.     The  forearm 

4.3 


674 


NOTES   UPON    A    FEW   DISLOCATIONS 


is  held  at  an  obtuse  angle.     There  may  be  great  swelHng  of  the 
elbow  if  the  injury  is  seen  several  hours  after  the  accident.     This 


Humerus 


Tig.  975. — Dislocation  of  the  radial  head.     Note  the  relative  position  of   the  radial  head  and  the 
coronoid  of  the  ulna.     A  rupture  of  the  superior  radio-ulnar  ligament  must  have  occurred. 

swelling  will  obscure  the  bony  relations.     Motion  at  the  elbow- 
joint  13  limited  and  painful. 

There  may  be  associated  with  a  simple  dislocation  of  the  elbow 
a  fracture  of  the  olecranon,  of  either  condyle  of  the  humerus  or  a 


^^^^^^^H^^^^^^v 

1^  ^HH 

^'^^H 

Head  of 

^^^             '^H 

^ftfi^^^^^^^^^l 

radius. 

^«     ^^^^^^^^1 

Fig.  976. — Old  dislocation  of  the  head  of  the  radius  outward  and  backward.  Functional 
usefulness  of  the  elbow  unimpaired.  Pronation  and  supination  normal.  In  such  a  disloca- 
tion were  there  present  any  serious  disability  excision  of  the  head  of  the  radius  would  be 
indicated.     (Codman.) 

fracture  of  the  coronoid  process.  If  there  is  any  doubt  as  to  the 
diagnosis,  ether  should  be  administered  to  facilitate  examination. 
As  Stimson  has  so  well  insisted,  in  the  reduction  of  any  disloca- 


DISIvOCATlON   OF   THE  ELBOW  675 

tion  the  dislocated  bone  should  be  reduced  by  the  same  path 
along  which  it  came  when  dislocated.  A  haphazard  method  of 
reduction  of  a  dislocation  is  unsurgical. 

The  best  method  of  reducing  a  dislocation  of  the  forearm  back- 
ward, when  uncomplicated,  is  by  two  steps:  first,  by  completely 
extending  the  forearm,  thus  freeing  the  coronoid  from  the  olec- 
ranon fossa  and  the  posterior  surface  of  the  humerus;  and,  second, 
by  direct  traction  and  then  flexing.  Reduction  is  best  accom- 
plished by  the  aid  of  an  anesthetic. 

Holding  the  arm  extended  and  pressing  with  the  two  thumbs 
upon  the  olecranon  process,  while  the  lower  end  of  the  humerus 
anteriorly  is  grasped  by  the  fingers  of  both  hands  in  counterpres- 
sure,  accomplishes,  of  course,  the  same  end  as  that  accomplished 


F'g-  977-— Same  case  as  figure  976.    Appearance  of  elbows  in  flexion  with  liands  at  side  of 

neck.     (Codman.) 

by  the  above  procedure,  and  is  in  many  cases  simple  and  efficient 
(see  Fig.  972). 

When  there  is  any  lateral  deformity,  the  bones  should  be  forced 
into  line  before  attempting  to  reduce  the  backward  dislocation. 

The  after-treatment  of  an  uncomplicated  dislocation  of  the 
elbow  is  by  immobilization  of  the  elbow,  with  the  forearm  at  a 
right  angle  with  the  upper  arm.  A  bandage,  with  equable  pres- 
sure, and  a  sling  to  the  forearm  should  be  applied. 

If  a  recurrence  of  the  dislocation  occurs  and  it  is  with  difficulty 
held  reduced  in  the  right -angle  position,  the  forearm  should  be 
flexed  to  an  acute  angle  after  the  reduction.  The  angle  of  flexion 
may  be  made  smaller  as  the  swelling  subsides. 

Massage  and  passive  motion  should  be  used  at  as  early  a  date 


676  NOTES    UPON   A    FBW   DISLOCATIONS 

as  the  second  day.     This  should  be  painless  and  should  be  ten- 
tatively employed. 

Good  functional  results  are  to  be  expected  from  uncomplicated 
dislocations  of  the  elbow  occurring  in  young  adults,  which  are 
reduced  soon  after  the  injury. 

UNREDUCED  DISLOCATIONS  OF   THE  ELBOW 

Reduction  of  a  dislocated  elbow  becom.es  after  a  very  few  weeks 
impossible.  The  disability  occasioned  by  the  unreduced  dislo- 
cation is  serious  in  most  instances.  Pain,  deformity  and  ankyl- 
osis more  or  less  complete  exist. 

The  chief  obstacle  to  reduction  of  the  dislocation  is  the  new  bone 
formed  by  the  stripped  up  periosteum  in  the  neighborhood  of  the 
joint.  Fibrous  tissue  forming  over  the  joint  surfaces  helps  to 
make  reduction  difficult  and  maintenance  of  reduction  almost 
impossible.  Certain  fractures  occurring  at  the  time  of  the  disloca- 
tion may  offer  additional  difficulties  to  reduction.  Prolonged  and 
violent  efforts  at  reduction  are  extremely  unwise  and  usually  futile. 

Operation  is  wise  in  these  cases.  That  method  is  the  best 
which  exposes  all  parts  of  the  elbow-joint  with  the  least  trauma. 
Through  this  incision  all  intra-articular  new  bone  and  all  adven- 
titious fibrous  tissue  are  to  be  removed,  the  dislocated  bones 
replaced  and  the  joint  closed.  Kocher's  external  lateral  incision, 
as  if  for  excision  of  the  elbow,  affords  easy  access  to  the  joint. 
Division  of  the  olecranon  (Trendelenburg)  may  facilitate  the 
procedure  at  times.  Two  lateral  incisions  will  occasionally  be 
found  serviceable.  Having  removed  all  adventitious  joint  tissue 
and  reduced  the  dislocation,  if  the  articular  surfaces  are  found 
damaged  and  there  are  losses  of  substance  in  the  articular  car- 
tilages it  may  be  wise  to  do  an    arthroplasty  upon  the  joint. 

An  arthroplasty  is  best  done  upon  the  elbow  by  placing  within 
the  joint  a  fat-fascial  flap  from  the  posterior  surface  of  the  upper 
arm.  The  damaged  bony  articular  surfaces  are  then  separated 
from  each  other  by  what  subsequently  assumes  the  function  of 
a  new  synovial  membrane. 

The  results  of  operation  upon  old  unreduced  dislocations 
of  the  elbow  are  satisfactory,  functionally. 


DISLOCATION    OF    FIRST   PROXIMAL   PHALANX    OF    THUMB      677 

COMPLETE  BACKWARD   DISLOCATION   OF  THE  FIRST    PROXI- 
MAL PHALANX  OF  THE  THUMB 

The  deformity  of  this  dislocation  is  well  shown  in  figure  978. 
The  articular  portion  of  the  base  of  the  phalanx  has  entirely  left 


r 


Fig.  978. — Backward  dislocation  of  lirst  phalanx  of  thumb.     Note  deformity. 


I'lK-  979- — Same  as  finure  978.     Nolc  head  of  metacarpal  and  how  it  is  held  liy  addiiilor  brcvis  and 

flexor  longus  pollici.s. 


Fig.  980. — Note  that  traction  alone  accomplishes  no  reduction,  but  a  very  tight  grasp  of  the  meta 
carpal  head  by  flexor  longus  pollicis  and  the  flexor  brevis. 


Fig.  981. — Proper  method  of  reduction.     Dorsal  flexion  of  thumbs  (true  extension);  traction  through 
dorsal  pressure  by  thumbs  so  that  base  of  phalanx  is  advanced  over  head  of  metacarpal. 


678 


Fig.  982. — Dorsal  dislocation  of  the  terminal  phalanx  of  the  thumb.  Reduced  by  forced 
extension  and  sliding  of  the  extended  phalanx  over  the  end  of  the  first  phalanx.  Note  com- 
plete separation  of  bones.     Glenoid  ligament  is  torn  and  attached  to  the  displaced  phalanx. 


Fill.  9S3. — Dorsal  dislocation  of  the  first  phalanx  of  the  thumb.  X-ray.  Rather  easily  re- 
duced by  slight  extension  and  traction.  Note  that  the  articular  surfaces  touch  each  other  at 
the  margins  of  the  bones 


679 


68o  NOTES   UPON    A    FEW   DISLOCATIONS 

the  articular  portion  of  the  head  of  the  metacarpal  bone.  The 
two  lateral  ligaments  are  torn.  The  anterior  or  glenoid  ligament 
is  likewise  torn  at  its  attachment  to  the  metacarpal  bone  and  is 
displaced  with  the  phalanx.  Ordinary  traction  only  serves  to 
increase  the  difficulty  of  reduction,  as  is  illustrated  in  figure  980. 
The  proper  method  of  manipulative  reduction  is  by  completely 
extending  the  thumb  so  as  to  relax  the  tight  adductor  brevis  and 
flexor  longus  pollicis  tendons  and  then  to  push  the  base  of  the 
phalanx  (see  Fig.  982)  forward,  advancing  at  the  same  time  the 
torn  glenoid  ligament  over  the  end  of  the  metacarpal  head; 
flexion  will  then  complete  the  reduction.     Immobilization  in  a 


Fig.  9S4. — Dislocation  of  the  bases  of  the  metacarpal  bones:  f,  Carpus;  M,  metacarpal;  R,  radius. 
.Arrow  points  to  wrist- joint  (Massachusetts  General  Hospital  clinic). 

straight  position  for  five  days,  and  after  this  painless  passive  and 
active  movements,  together  with  massage,  are  indicated.  Should 
reduction  be  impossible  by  manipulation,  operative  treatment 
will  become  necessary. 

DISLOCATION  OF  THE  HIP 

A  line  drawn  from  the  anterior  superior  spinous  process  of  the 
ilium  to  the  tuberosity  of  the  ischium  passes  about  midway  across 
the  acetabulum.  The  portion  of  the  bony  pelvis  posterior  to  this 
line  is  called  the  outer  plane  of  the  pelvis.  The  portion  of  the 
pelvis  anterior  to  this  line  is  called  the  inner  plane  of  the  pelvis 
( Allis) .  The  hip  is  dislocated  by  a  force  bringing  leverage  to  bear 
upon  the  head  of  the  bone  when  the  thigh  is  flexed  upon  the  ab- 
domen. The  head  of  the  femur  leaves  the  acetabulum  through 
a  rent  in  the  under  portion  of  the  capsule  of  the  joint. 


DISLOCATION   OF   THE    HIP. 


68 1 


The  first  movement  of  the  head  in  being  dislocated  is  down- 
ward. According  as  the  head  of  the  bone  shps  to  the  outer  or  the 
inner  plane  of  the  pelvis  will  the  dislocatien  be  classified  as  an 
outer  or  an  inner  dislocation ;  that  is,  a  posterior  or  an  anterior 
dislocation.  Of  course,  in  either  position,  whether  the  outer  or 
the  inner,  the  head  of  the  bone  may  be  high  up  or  low  down.    The 


Fig.  985. — Dislocation  of  the  right  hip-joint.     The  head  of  the  femur  resting  upon  the  dorsum  of  the 
ilium.     Note  the  adduction  and  flexion  of  the  thigh  in  characteristic  attitude. 

anterior  portion  of  the  capsule  of  the  hip-joint  is  far  thicker  than 
any  other  portion  of  the  capsule.  This  thickened  portion  Bige- 
low  called  the  Y-ligamcnt. 

Symptoms. — The  symptoms  of  an  outward  or  dorsal  dislocation 
of  the  hip:  The  limb  is  inverted,  somewhat  shortened,  fiexed 
slightly  upon  the  abdomen,  the  toes  of  the  dislocated  limb  rest 


682 


NOTES   UPON   A   FEW    DISLOCATIONS 


Upon  the  instep  of  the  other  foot,  the  head  of  the  bone  can  be 
felt  above  the  acetabulum.  The  adduction,  flexion,  and  the  rolling 
inward  of  the  limbs  are  signs  of  a  dislocation  of  the  hip  outward. 
The  symptoms  of  an  inward  or  anterior  dislocation:  The  thigh 
is  flexed  upon  the  abdomen,  abducted,  rotated  outward;  the  heel 
is  raised,  the  foot  everted. 


Fig.  9S6. — Dorsal  dislocation  of  the  left  hip.     Note  the  characteristic  altitude.     The  knee  is  more 
adducted  than  in  case  of  Fig.  983. 

Reduction. — The  method  of  reduction  of  sn  outward  or  dorsal 
dislocation :  Stimson  advises  very  properly  the  passive  method 
in  uncomplicated  cases.  The  patient  is  placed  prone  on  a  table, 
the  dislocated  leg  is  ahowed  to  hang  over  the  end  of  the  table 
while  the  sound  leg  is  held  in  line  with  the  body  by  an  assistant. 
The  surgeon  grasps  the  ankle  of  the  dislocated  leg  and  flexes  the 
knee  to  a  right  angle.  The  weight  of  the  leg  pulHng  on  the  mus- 
cles about  the  hip  gently  but  evenly  often,  aided  by  pressure  on 


DISLOCATION    OF   THE    HIP 


683 


the  calf  of  the  flexed  leg  on  the  part  of  the  surgeon,  will  reduce  the 
dislocation.  A  slight  rocking  of  the  leg  may  facilitate  reduction. 
Allis'  Method.- — The  patient  lying  supine,  the  pelvis  being  held 
fixed  by  two  assistants,  the  surgeon  kneels  by  the  patient's  side, 
and  if  the  right  femur  is  dislocated  he  grasps  the  ankle  with  his 


Fig.  987. — Anterior  dislocation  of  the  right  hip.     Note  characteristic  cversion  and  altitude  of  the 
right  lower  extremity.     (Case  of  Burrell,  Boston  City  Hospital  clinic.) 


right  hand  and  places  the  bent  elbow  of  his  left  arm  beneath  the 
popliteal  space:  (i)  he  now  turns  the  bent  leg  outward  and  lifts 
upward  (skyward) ;  (2)  then  turns  the  bent  leg  inward  and  brings 
the  femur  down  in  extension. 

The  method  of  reduction  of  an  inward  or  anterior  dislocation: 


68d 


NOTES   UPON   A   FEW    DISLOCATIONS 


A  His'  Direct  Method. — ( i )  Flex  and  abduct  the  femur.  (2)  Make 
traction  outward.  (3)  Fix  the  head  by  digital  pressure  and 
adduct. 

Allis'  Indirect  Method. — Extension,  adduction,  and  outward 
rotation  are  the  movements  made.  The  patient  is  lying  on  the 
floor  on  a  blanket  with  the  femur  flexed.  The  surgeon  places  his 
bent  elbow  beneath  the  flexed  knee  and  grasps  the  ankle  with  the 


Fig.  988. — Posterior  or  dorsal  dislocation  of  the  left  hip.  Note  the  characteristic  altitude  of  the 
left  lower  extremity.  Flexion,  adduction,  inversion  of  the  thigh.  (Case  of  Burrell,  Boston  City 
Hospital  clinic.) 

other  hand ;  he  then  extends  with  traction  in  the  line  of  the  long 
axis  of  the  femur,  adducts,  and  rotates  outward. 

Bigelow's  Method  of  Reduction  of  a  Dorsal  or  Posterior  Disloca- 
tion.— The  patient  lies  in  same  position  as  described  above  in 
Allis'  method.  The  thigh  is  flexed,  adducted,  slightly  inverted, 
lifted,  circumducted  outward  and  extended. 

Bigelow's  Method  of  Reduction  of  Thyroid  or  Anterior  Disloca- 
tion.— The  thigh  is  flexed  on  abdomen  to  a  right  angle,  abducted, 
and  rotated  inward  with  adduction  and  is  finally  extended. 


DISLOCATION  OF  THE  PATELLA 


Fig.  989. — Lateral  dislocation  of  right  patella  (Massachusetts  General  Hospital). 


Fig.  ygo. — Incomplete  dislocation  of  the  right  patella  outward.  Its  inner  border  rested  in 
the  intercondyloid  notch.  Reduced  by  ether  and  lifting  and  pushing  into  place.  Same  case 
as  that  seen  in  figure  989.    Reduction  is  usually  easy  (Massachusetts  General  Hospital). 


685 


BIBLIOGRAPHY 

The  important  contributions  to  literature  whicli  liave  been  consulted  are  recorded 
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in  its  especial  field.  Dr.  Poland's  work  upon  "The  Epiphyses"  is  also  a  very 
valuable  contribution  to  fracture  literature.  The  text  has  been  kept  free  of  all 
references  in  order  that  greater  clearness  might  result. 


Hamilton,  Fractures  and  Dislocations. 

Stimson,  A  Practical  Treatise  on  Fractures  and  Dislocations,  Lea  Bros.,  1899. 

Helferich,  Atlas  of  Traumatic  Fractures  and  Luxations,  with  a  Brief  Treatise,  Wm. 

Wood  &  Co.,  1896. 
Roberts,  P.  Blakiston,  Son  &  Co.,  Philadelphia,  1897. 
Wharton  and  Curtis,  The  Practice  of  Surgery. 

The  Liternational  Encyclopedia  of  Surgery  ;  supplementary  volume  VII,  1895, 
Dennis,  F.  S.,  System  of  Surgery,  1895. 
Cheever,  Lectures  on  Surgery,  Damrell  and  Upham,  Boston,  1894. 

OBSTETRICAL  FRACTURES 
Kerr,  J.  M.  M.,  London  Lancet,  January  19,  1901. 

FRACTURE  OF  THE  SKULL 

Huguenin,  Cyclopaedia  practische  Medicin,  Ziemssen,  Band  XII,  1897. 

Mills,  The  Nervous  System  and  Its  Diseases,  1898. 

Bradford  and  Smith,  Transactions  of  the  American   Surgical  Association,  volume 
LX,  page  433. 

Bullard,  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  1897;  also 
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Dana,  Text-book  of  Nervous  Diseases. 

Courtney,  Boston  Medical  and  Surgical  Joarnal,  April  6,  1899,  page  345. 

Hill  and  Bayliss,  Journal  of  Physiology,  London,  1895,  XVIII,  page  324. 

Walton,  American  Journal  of  Medical  Sciences,  September,  1898. 

Putnam,  Walton,  Scudder,  Lund,  American  Journal  of  Medical  Sciences,  April, 
1895. 

Phelps,  Traumatic  Injuries  of  the  Brain. 

Walton,  Annals  of  Surgery,    November,    1Q04. 

Matas,  New  Orleans  Medical  and  Surgical  Journal,  September,  1896. 

Lothrop,  Boston  Medical  and  Surgical  Journal,  January  4,  1906. 

Matas,  Annals  of  Surgery,  January,   1905. 

Rawling,  Lancet,  London,  1904,  vol.  i. 

Connell,  Surgery,  Gynecology   and  Obstetrics,  March,  1906. 

English,  The  London  Lancet,  vol.  i,  1904. 

Crandon  and  Wilson,  Annals  of  Surgery,  December,  1906. 

Thomas,  Fractures  of  the  Base  of  the  Skull,  Injuries  of  Cranial  Nerves  Follow- 
ing, Journal  of  the  American  Medical  Association,  July  25,  1908,  p.  271. 

686 


BIBLIOGRAPHY  687 

FRACTURE  OF  THE  NASAL  BONES 

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Evans,  Deflections  of  the  Nasal  Septum,  Louisville  Journal  of  Surgery  and  Medi- 
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volume  XXX,  1898,  page  588. 

Freytag,  Monatschrift  fiir  Ohrenheilkunde,  1896,  Band  xxx,  Seiten  217-224. 

Zuckerkandl,  Anatomie  der  NasenhShle,  Band  11. 

Watsin,  Lancet,  1896,  volume  i,  page  972. 

Roe,  The  American  Medical  Quarterly,  June,  1899. 

FRACTURE  OF  THE  SPINE 

Thorburn,  A  Contribution  to  the  Surgery  of  the  Spinal  Cord. 

Walton,  Boston  Medical  and  Surgical  Journal,  December  7,  1893.      The  Journal  of 

Nervous  and  Mental  Diseases,  January,  1902. 
Thomas,  Boston  Medical  and  Surgical  Journal,  September  7,  1899,  page  233. 
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Burrell,  Transactions  of  the  Massachusetts  Medical  Society,  1887. 
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1898,  Seite  415. 
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Prewitt,  Transactions  American  Surgical  Association,  volume  XVI,  page  255, 
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FRACTURE  OF  THE  SCAPULA 
Blake,  Boston  City  Hospital  Reports,  1899,  page  368. 

FRACTURE  OF  THE  HUMERUS 

Bruns,  Deutsche  Chirurgie,  Theil  28,  2.  Halfte. 
Murray,  New  York  Medical  Journal,  June  25,  1892. 

Monks,  Boston  City  Hospital  Medical  and  Surgical  Reports,  1895  ;  also  Boston  Medr 
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AlUs,  Annals  of  the  Anatomical  and  Surgical  Society,  Brooklyn,  1880,  11,  289. 
Smith,  Boston  Medical  and  Surgical  Journal,  October,  1894,  and  July,  1895. 
Dulles  and  Jones,  Boston  Medical  and  Surgical  Journal,  August,  1894. 
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Stone,  Boston  Mcflical  and  Surgical  Journal,  August,  11,  1904. 
Scudder  and  Barney. 

VOLKMANN'S  CONTRACTURE 
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688  BIBLIOGRAPHY 

Barnard,  The  London  Lancet,  April  20,  1901. 
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Thomas,  J.  J.,  Annals  of  Surgery,  1909,  volume  xlix,  p.  330  (a  complete  bibli- 
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Pilcher,  Paper  read  to  Association  of  Military  Surgeons  of  the  United  States,  Berlin 
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Moore,  Transactions  of  the  Medical  Society,  State  of  New  York,  1880. 

BoUes,  Boston  City  Hospital  Reports,  third  series,  1882,  page  340. 

Conner,  Journal  of  the  American  Medical  Association,  1894,  page  54. 

Roberts,  Medical  News,  1890,  LVii,  615.     Annals  of  Surgery,  1892,  xvi. 

Mouchet,  A.,  Revue  de  Chirurgie,  May,  1900.. 

Codman  and  Chase,  Fracture  of  Scaphoid,  Annals  of  Surgery,  March  and  June, 
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Lothrop,  H.  A.,  Operative  Treatment  of  Old  Fractures  at  Lower  End  of  Radius, 
Boston  Medical  and  Surgical  Journal,  December  7,  1905. 

Painter,  C.  F.,  Boston  Medical  and  Surgical  Journal,  Oct.  30, 1902.     Osteomyelitis. 

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329.      Medical  News,  November  21,  1891. 
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March    19,    1904.     New   York   Medical    News,    September    24,    1904.     The 

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689 


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Liverpool  Medicochirurgical  Journal,  January,  1885,  page  41. 

Liverpool  Medicochirurgical  Journal,  July,  1883. 

Stimson,  Fractures  and  Dislocations,  1899. 

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Powers,  Annals  of  Surgery,  July,  1898. 

Bull,  New  York  Medical  Record,  xxxvii,  1890. 

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44 


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Dent,  C,  British  Medical  Journal,  1900,  il,  632  and  634. 

MacCormac,  Sir  Wm.,  London  Lancet,  1900,  i,  1485. 

Thomson,  Sir  Wm.,  British  Medical  Journal,  1 901,  ii,  265.     London  Lancet,  li, 

1901,  264. 
Nancrede,  Transactions  of  the  American  SSurgical  Association,  1899,  1900. 
Hall,  Edward  J.,  London  Lancet,  1 901,  i,  130,  1755. 

THE  AMBULATORY  TREATMENT  OF  FRACTURES 

Krause,  Deutsche  medicinische  Wochenschrift,  1891,  No.  13. 

Korsch,  Berliner  klinische  Wochenschrift,  No.  2. 

Bruns,  Beitrage  zur  klinische  Chirurgie,  Band  X,  Heft  II,  18. 

Dollinger,  Centralblatt  fiir  Chirurgie,  1893,  No.  46. 

Warbasse,  Transactions  of  the  Brooklyn  Surgical  Society,  October,  1894. 

Bardeleben,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kon- 

gress,  1894. 
Albers,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kongress, 

1894. 
Krause,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kongress, 

1894. 
Pilcher,  Transactions  of  the  American  Surgical  Association,  volume  XI v,  1896. 
Woodbury,  New  York  Medical  Record,  1897. 

Roberts,  Transactions  of  the  American  Surgical  Association,  volume  XIV,  1896. 
Woolsey,  New  York  Medical  Record,  1897. 
Cabot,  New  York  Medical  Record,  1897. 
Bradford,  New  York  Medical  Record,  1897. 

THE  EPIPHYSES 
Quain,   Dwight,   Gray,   Morris. 

Poland,  John,  f.r.c.S.,  Traumatic  Separation  of  the  Epiphyses,  1898. 
Briinne,   Das   Verhaltniss   die   Gelenkkapselen  zu   die  Epiphyse  die  Extremitaten- 

Knochen. 
Joiion,  E.,  Revue  D' orthopedic,  Paris,  2e  serie,  3.      1902. 

MASSAGE 
Bennett,  W.  H.,  London  Lancet,  June  2,  1900;   London  Lancet,  Feb.  5,  1898. 

DISLOCATIONS 

Unreduced  Dislocations  of  the  Elbow 

Stimson,  N.  Y.  Medical  Journal,  October  24,  1891. 

Trendelenburg,  Archiv.  fur  klin.  Chir.,  1879,  vol.  xxiv.,  p.  790. 

Bunge,  Archiv.  f.  klin.  Chir.,  vol.,  Ix,  p.  557. 

Rixford,   Trans.   Am.   Surg.   Association,    1903. 

Murphy,  Arthroplasty  Jour.  Am.  Med.  Assoc,  1905. 

Sheldon,  Acromioclavicular  dislocation,  Annals  of  Surgery,  September,  1903. 

PATHOLOGICAL  FRACTURES 
Simmons,  C.  C,  Osteogenesis  Imperfecta,  Annals  of  Surgery,  August,  1907. 
Nichols,  E.  H.,  Keen's  Surgery,  volume  li,  1907. 


INDEX 


Abscess  of    brain  following   fracture 
of  base  of  skull,  28,  48 
of  jaw,  87 
Acromial  process  of  scapula,  584 
Active    motion    after    dislocation    of 
thumb,  680 
after  fracture  of  elbow,  260 
of  leg,  518 
of  patella,  469 
of  radius,  291 

of  scaphoid  bone  of  wrist,  355 
of  shaft  of  femur,  432 
after  separation  of  lower  femoral 

epiphysis,  453 
in  CoUes'  fracture,  349 
Adhesions   following   fracture  of    pa- 
tella, 467,  469 
Adhesive  plaster  in  Colles'   fracture, 
346 
in  fracture  of  clavicle,   148,   149, 
150,  152 
of  elbow,  252,  253 
of  femur,  neck  of,  391 

shaft  of,  419 
of  humerus,  202,  206,  212 
of  leg,  504,  505 

of  metacarpal  bones,  363,  365 
of  nasal  bones,  62 
of  olecranon,  318 
of  patella,  463 
of  phalanges,  373 
of  radius  and  ulna,  305 
of  rib,  124 

application  of,  124 
of  scapula,  159 
of  sternum,  129 
in  Pott's  fracture,  531 
Albee,     reduction    in    separation    of 

upper  epiphysis  of  humerus,  176 
Albers   (quotedj,    use  of  morphin   in 

ambulatory  treatment,  637 
Aluminium  or  tin  finger-splint,  374 
Ambulatory  treatment,  636 

of  fracture  of  clavicle,  148 
of  humerus,  183 
of  thigh,  385,  434 
of  fractures,  636 

advantages  claimed,  640 
conclusions,  642 
early  advocates,  636 


Ambulatory  treatment  of  fractures, 
materials  for  ordinary  care 
of  closed  fractures,  643 

method  of  application  of  plas- 
ter splint   (Bollinger's),  638 

report  of  cases,  641 
American  Surgical  Association,  Com- 
mittee from  (quoted),  requis- 
ites for  satisfactory  result 
following  fracture  of  femur, 
436 

conclusions    expressing    views 
of,  upon    medicolegal     rela- 
tions of  -X-rays,  adopted  in 
May,   1900,  611 
Anatomical  neck  of  humerus,  167 

after-treatment     of     operated 
cases,   1 88 

fracture  of,  with  dislocation  of 
upper  fragment,  169 

impacted  fracture,  169 

treatment,  169 

Anesthetics,   use   of,  in  examination: 

of  Colles'  fracture,  326,  330 

of  femur,  neck  of,  381 
shaft  of,  416 

of  fracture  of  elbow,  243,  266 
in  dislocation,  674 

of  humerus,  162,  165 
anatomical  neck  of,  168 
surgical  neck  of,  162 

of  leg,  489 

in  open  fracture,  514 

of  maxilla,  superior,  61 

of  nasal  bones,  61 

of  separation  of  upper  humeral 
epiphysis,   178 

of  shoulder,  162 
in  treatment,  555 

of  Colles'  fracture,  341,  353 

of  dislocation  of  cervical  ver- 
tebrae, 650,  651 
of  elbow,  674 
of  jaw,  652 
of  shoulder,  670 

of  fracture  of  clavicle  in  chil- 
dren,  150 
of  femur,  shaft  of,  416 
of  humerus,  178,  206 
of  jaw,  652 


692 


INDEX 


Anesthetics,  use  of,  in  treatment  of 
fracture  of  leg,  514 
of  malar  bone,  70 
of  radius  and  ulna,  296 
of  vertebrae,  117 
of  greenstick  fracture  of  fore- 
arm, 310 
of  Pott's  fracture,  527,  530 
of    unreduced    dislocations    of 
shoulder,  670 
Ankylosis  of  ankle-joint,  551 
of  elbow,  676 
of  shoulder,  188 
Arthritis,    chronic,    after   fracture   of 
leg,  520 
infectious,     causing     ankylosis     of 

shoulder-joint,  188 
peri-,  following  injury  to  shoulder, 
184 
Arthroplasty  upon  elbow,  676 

upon  humerus,  190 
Asch  tube,  62 

Aspiration  of  knee-joint,  465 
Astragalus,  543 
open  fracture,  551 

operative  treatment,  551 
prognosis,   545 
results,  547 
symptoms,  543 
treatment,  547 
Atrophy,  muscular,  after  fracture  of 
humerus,  212,  219 


Bandage,  dextrin,  634 
application,  634 
formula,  634 
elastic  rubber,  461 
flannel,  after  Pott's  fracture,  534 
in  fracture  of  humerus,  181,  200, 
206 
of  OS  calcis,  550 
of  patella;  466 
in   separation   of   lower   femoral 

epiphysis,  453 
substituted  for  plaster  splint,  518 
four-tailed,  in  fracture  of  lower  jaw, 

78 
plaster-of-Paris,  73,   116,  512,  614, 

631 
roller,  in  Colles'  fracture,  347 
in  fracture  of  elbow,  255,  256 
of  femur,  neck  of,  391 

shaft  of,  419 
of  humerus,  200,  206,  209 
of  metacarpal  bones,  372 
of  patella,  466 
in  Pott's  fracture,  520 
Velpeau,  150 
Bardeleben      (quoted),      ambulatory 
treatment,  cases  reported,  637 


Bardeleben,  law  concerning  ambula- 
tory treatment,  637 
Base  of  skull,  25,  28,  30 
anterior  fossa,  31 
cribriform  plate  of  ethmoid,  31, 

48 
drainage  of  fossa,  44 
hemorrhage,  30,  32 
involvement    of,    in    fracture  of 
maxilla,  superior,  71 
of  nasal  bones,  64 
middle  fossa,  31 
nature  of  fractures,  28 
orbital    plate    of    frontal    bone, 

31 
petrous  portion  of  temporal  bone, 

31 
posterior  fossa,  32 
relation  to  fracture  of  vault,  28 
s^Tnptoms,  30,  31,  32 
Base-ball  finger,  373 
Beach,  case  of  musculospiral  paralysis, 

218 
Bed-sores,  94,  119,  388 

treatment,  388 
Bennett's  fracture,  362 
Bibliography,  686 
Bladder  (urinary),  rupture  of,  139 
symptoms,  139 
treatment,  operative,  140 
Blebs,  492,  499 

treatment,  499 
Blood-vessels,    lesions   of,    in   separa- 
tion of  lower  femoral  epiphysis,  477 
Bolton  (quoted),  fracture  of  neck  of 

femur  in  childhood,  408 
Bone  cysts  as  a  cause  of  fracture,  565 
treatment,  565 
plates  and  screws  (Lane's),  561,  562 
staples  (Huntington's),  561 
Borden  (W.  C.)  (quoted),  585 

infection   in  gunshot  wounds,  592, 

593.  594 
prognosis  in  gunshot  wounds,  594 
treatment  of  gunshot  wounds,  592, 

593,  594 
Bradford    (E-    H.),    treatment    with 

modified  Thomas  knee-splint,  638 
frame,  132,  415,  444 

making  of,  444 
myotomy  of  muscles  for  Volkmann's 

contracture,  271 
Brain,  abscess  of,  44 
compression  of,   19,  20 
concussion  and  contusion  of,  17,  45, 

46 
extradural  hemorrhage,  20 
laceration  of,  18 

subarachnoid  serous  exudation,  24 
traumatic  lesions  of,  17 
symptoms,  17 


INDEX 


693 


Brain-tissue,  escape  of,  in  fracture  of 

base  of  skull,  30 
Brown  (P.),  x-ray  of  fracture  of  both 
bones  of  forearm  above  wrist,  288 
Bruns,    musculospiral    paralysis,    219 
Bryant's     method     of     measurement 
after  fracture  of  neck  of  femur,  383 
Buck's    extension    apparatus    (modi- 
fied), 419 
application,  420 
in  childhood,  440 
materials  required,  419 
BuUard       (Boston     City     Hospital) 
(quoted) ,  results  of  fracture  of  skull, 

49 
Burrell  (Boston  City  Hospital),  illus- 
trations of  dislocation  of  hip,  683, 


Cabot  and  Binney,  x-rays  of  results 
of   fracture   of   astragulus    and   os 
calcis,  551 
Cabot   (A.  T.),  use  of  Taylor's  long 
hip-splint,  638 
posterior  wire  splint,  441,  531,  532 
application,  441 
covering,  441 
making,  441 

padding  of,  for  reception  of 
lower  extremity,  504 
Cabot   (Hugh),  method  of  mobiliza- 
tion of  urethra  in  rupture  follow- 
ing fracture  of  pelvis,- 138,  139 
Carcinoma,  metastatic,  as  a  cause  of 

fracture,  564 
Carpus,  355 
scaphoid,  355 
treatment,  359 

operative,  360,  361 
Cerebrospinal    fluid,     escape    of,     in 

fracture  of  base  of  skull,  30 
Character,  changes  in,  following  head 

injuries,  47,  48 
Chase,    report    of    Mixter's    case    of 

transverse  lesion  of  cord,  no 
Chutro,  musculospiral  paralysis,  241 

injury  to  elbow,  263,  264 
Clavicle,  141 
anatomy,  141 
prognosis,  152 
symptoms,  142 

in  childhood,  143 
treatment  in  adults,   144 

modified  Sayre  dressing,  148 
recumbent,   144 
in  children,  150 
operative,  153 

in  ununited  fractures,  154 
Cobb's  splint,  62 

Codman  and  Chase,  x-ray  illustrations 
of  fracture  of  scaphoid,  357,  358 


Codman    (Ernest    Amory),    Rontgen 
ray  and  its  relation  to  fractures, 
598 
(quoted),  treatment  of  fracture  of 
scaphoid  bone  of  wrist,  361 
Codman's  method  of  taking  an  x-ray 
of  the  scaphoid,  361 
of  raising  depressed  malar  bone,  70 
Colles'  fracture,  323 
after-care,  354 
anatomy,  324 
causes  of,  323 
differential  diagnosis,  335 

contusion     of     bones     near 

wrist-joint,  336 
dislocation    of    wrist    back- 
ward, 337 
fracture  of  shaft  of  one  or 
both  bones  low  down,  337 
separation  of  lower  epiphysis 

of  radius,  339 
sprain  of  wrist,  336 
lesions  associated  with,  341 
old    fractures    at    lower    end    of 

radius,  351 
prognosis  and  result,  350 
"reversed  "  Colles'  fracture,  350 
symptoms,  326 
treatment,  341 

method  of  reduction,  342 
operative,     for     resulting     de- 
formity, 351 
method  of  operating  (Loth- 
rop's  technique),  353 
retentive  apparatus,  345 

application  of,   345,   346 
Coma,  35,  38 
alcoholic,  35 

from  opium-poisoning,  32 
Compression  of  brain,  19,  20 

symptoms,  19 
Concussion  and   contusion   of  brain, 

17,  45,  46 
symptoms,  17,  45,  46 
temperature,  18,  46 

Consciousness  and  unconsciousness 
in  extradural  hemorrhage,  19,  20 

Contracture,  Volkmann's,  266 

Contusion  of  bones  near  wrist- joint, 
336 

Coolidge's  splint,  63 

Coracoid  process  of  scapula,  164 

Coxa  vara,  409 

Cradle,  420,  427 

Crandon  and  Wilson  (quoted),  case 
of  head  injury,  54 

Curtis,  results  of  excision  of  shoulder- 
joint,  190 

Cushing,  Cannon  (quoted),  symptoms 
of  compression  in  intracranial  hem- 
orrhage, 21,  45 


694 


INDEX 


Cusbing  (E.  H  ),  dissection  of  nerves 
in  Volkmann's  contracture,  271 

Cystitis  after  fractures  of  vertebrae, 
94.  104,  117 


DandridgE  (N.  p.),  ambulatory  treat- 
ment, cases  reported,  638 

Davidsohn,  lengthening  of  flexor 
tendons  in  Volkmann's  contracture, 
271 

Davison,  method  of  suspending  lower 
limb  in  fracture  of  thigh  in  children, 

443 
Deformity  after  fracture  of  clavicle, 
152 
of  femur,  neck  of,  376,  385 
shaft  of,  410 

backward  sagging,  425 
aversion  of  foot,  426 
outward  bowing,  426 
of  humerus,  185 
of  leg,  487,  491 
of  malar  bone,  68 
of  nasal  bones,  64 
of  rib,  124 
in  Colles'  fracture,  327,  351 
anteroposterior,  327 

silver-fork,  327 
lateral,  327 

slight  deformity  only,  330 
in  fracture  of  clavicle,   148,   152 
of  elbow,  256 

of  metacarpal  bones,  362,  372 
of  phalanges   (hand),   373 
of  radius,  shaft  of,  293 

and  ulna,  284 
of  skull  in  newborn,  55 
of  vertebrae,  94,  115 
in  greenstick  fracture  of  bones  of 

forearm,  284,  310 
in  Pott's  fracture,  527,  529 
anteroposterior,  529 
of  lateral,  527 

reversed  Pott's  deformity,  527 
in  separation  of  epiphysis : 

humeral,  upper,  170,  172 
radial,   lower,   295 
Dislocation  of  hip,  379,  384,  680 
of  humeral  head,  166,  186 
reduction,    186 
results,   186 
treatment,   186,   187,  188 
operative,   187,   188 
of  knee,  685 

of  radius  and  ulna  backward,  with 
or  without  fracture  of  coro- 
noid  process  of  ulna,  232 
treatment,  234 
of  vertebrae,  92,  102 
of  wrist,  backward,  337 


Dislocations,  notes  upon,  644 

of  acromioclavicular  joint,   658 
illustrative  cases,  658 
lesions  of  ligaments,  658 
symptoms,  658 
treatment,  659 
operative,  659 

indications  for,  659 
of  cervical  vertebrae,  644 
bilateral,  644 

combined    with    a    fracture 
of  an  articular  process,  649 
precautions,  651 
spontaneous   reduction,    650 
treatment,  650 

of  bilateral  dislocation,  651 
unilateral,  650 

signs,   650 
untreated  cases,  650 
of  clavicle,  658 
of  elbow,  673 

after-treatment,  675 
associated   with   fracture,    674 
signs,  673 
treatment,  675 
unreduced   dislocations,    676 
obstacle  to  reduction,  676 
operation,  676 
of  hip,  680 

reduction,  682 
Allis'  method,  683 
Stimson's  method,  682 
reduction  of  a  dorsal  or  poste- 
rior    dislocation,     Bigelow's 
method,  684 
of  an   inward  or  anterior  dis- 
location,       Allis'       direct 
method,  684 
indirect  method,  684 
Bigelow's  method,  684 
sj^mptoms,  681,  682 
of  jaw,  65 1 
signs,  651 

spontaneous   reduction,   65 1 
treatment,  652 

of    irreducible    dislocations, 

654      .         . 
of  recurring  dislocations,  654 
of  patella,  685 
of  shoulder,  661 

associated   with   fracture,    663 
old  unreduced  dislocations,  666 

treatment,  666 
recurrent   dislocations,  666 
signs,  661 
treatment,  663 

after-reduction,  667 
Kocher's  method,  664 
unreduced   dislocations,   668 
causes     of     irreducibility, 
670 


INDEX 


695 


Dislocations  of  shoulder,  unreduced, 
end    results    after   exci- 
sion of  shoulder  for  dis- 
location fracture,  671 
method  of  attempting  re- 
duction, 670 
operative    procedures    for 
irreducible     disloca- 
tion   of        humeral 
head,   670 
if  fracture  exists,  670 
if  no  fracture  exists, 
670 
of    thumb,    complete    backward 
dislocation  of  first  proxi- 
mal phalanx,  677 
signs,  677 
treatment,  680 
operative,   680 
Dodd,  x-rays  of  separation  of  radial 
epiphysis,  290,  291 
of  epiphysis,  573,  574,  577,  578, 
579>  580,  581,  582 
Dollinger's  method  of  application  of 
plaster  splint  in  ambulatory  treat- 
ment of  fractures,  637 
Drainage    after    fracture    of    base    of 
skull,  of  fossa  involved,  44 
of  superior  maxilla,   74 
in  open  fracture  of  leg,  516 
in  Pott's  fracture,  536 
of  antrum,  72 
of  mouth,  72,  74 
Dudgeon   (quoted),  Volkmann's  con- 
tracture, 267 
Dupuytren  splint,  468 
application,  468 
defect,  468 


EcCHYMOSis  in  fracture  of  leg,  492 

of  skull,  31,  32 
Edema,   causes  of,   after  fracture  of 
leg  or  thigh,  521 
cerebral,  24 
malignant,  454 
Elbow,  227 

after-care,  258 
method  of  examination,  227 
carrying  angle,  229 
head  of  radius,  228 
measurements,   229 
movements  at  elbow-joint,  229 
palpation    of    the    three    bony 

points,  228 
summary  of  order  of  examina- 
tion, 231 
the  three  bony  points,  228 
omission  of  splint  or  retentive  ap- 
paratus, 260 
prognosis,  263 


Elbow,  traumatic  lesions,  232 
diagnosis,  234 

of  lower  end  of  humerus,  234 
of  radius  and  ulna,  232 
symptoms,  234,  235,  236,  237, 
238,  240,  241 
treatment,  244 

acutely  flexed  position,  249,  265 
method  of  using,  249 
precautions  in  using,   252 
Volkmann's  contracture,  266 
treatment,  271 
operative,   271 
Elbow-joint,  treatment  of,  in  fracture 

of  shaft  of  humerus,  244 
Electricity   after   fracture    of     upper 

end  of  humerus,  188 
Elevating  fractured  bones: 
malar,  70 

maxillary,  superior,  72 
nasal,  62 
sternum,  129 
Embolism,  455 
fat,  454 

cerebral  type,  455 
pulmonary  type,  455 
diagnosis,  455 
symptoms,  455 
treatment,  455 
Emergency  method  of  putting  up  a 

fracture  of  thigh  or  hip,  413 
Emphysema     in     fracture     of     nasal 
bones,  59 
of  ribs,  122,  126 
of  superior  maxilla,  72 
English  (quoted),  later  results  of  head 

injuries,  47 
Epilepsy,  traumatic,  49 

treatment,  operative,  49 
Epiphyses,    anatomical   facts   regard- 
ing the,  571 
acromion  process  of  scapula,  584 
date  of  appearance   of   ossification 
in  chief  epiphyses  of  long  bones 
(after  Poland),  571 
femur,  lower  epiphysis,  583 
humerus,  upper  epiphysis,  572 
activity  of,  in  growth  of  shaft,  583 
lower  epiphysis,  584 
importance  of  exact  knowledge,  571 
order   of    frequency    of   separation 

(after  Poland),  572 
pain    in    separation    of    epiphyses 
compared  with   pain   from  frac- 
tures,  572 
radius,  lower  epiphyses,  293 
separation  of,  age  of  occurrence,  295 
tibia,  lower  epiphysis,  584 

upper  epiphysis,  584 
union  of,  with  shaft  of  bone,  age  of 
occurrence,  584 


696 


INDEX 


Epiphysis,    fracture   of   lower   radial, 

304,  339 
injury  to  lower  humeral,  240 

diagnosis,  241 
separation  of,  femoral,  lower,  445, 
558 
anatomy,  445 
complications,   454 
diagnosis,  447 
prognosis,  448 
symptoms,   448,   449 
treatment,  450 

of     trauraatic     gangrene, 
septicemia,      malignant 
edema,  453 
operative    method    of    re- 
duction, 452 
reduction     by     manipula- 
tion  when   fragment   is 
displaced    forward,    45 1 
humeral,  lower,  240 
treatment,  257 
upper,  169,  572,  583 

arrested  growth  of  bone,  177 
prognosis,  177 
treatment,   172 

operative,  172,  177,  558 
with    dislocation    of    upper 
fragment,  186 
after   treatment    of   oper- 
ated cases,  188 
treatment,   186 
radial,  lower,  304,  339 

treatment,  304,  341 
tibial,  lower,  485,  493 
upper,  485 
of  acromion  process  of  scapula,  584 
Excision  of  head  of  humerus,  187 
results,  188 
of  shoulder- joint  for  fracture    and 
dislocation,  188 
results,  189,  190,  191 
Extension   weights   after   fracture   of 
pelvis,  132 
of  femur,  neck  of,  391 
shaft  of,  424,  425,  426 
Extravasation,  subarachnoid,  in  frac- 
ture of  skull,  37 
of  urine,  140 

in  fracture  of  pelvis,  140 


Face,  bones  of,  fractures  of,  56 
malar  bone,  67 
maxilla,  inferior,  74 

superior,  58,  71 
nasal  bones,  56,  58 
Feeding,    after    fracture    of   jaw,    by 
mouth,  74 
nasal,   74 
Femur,  410 


Femur,  after-treatment  and  prognosis, 

431 
examination,  method  of,  416 
gunshot  fracture,  585 
mortality,   596 

comparative,      in      different 
wars,    596 
prognosis,  590 
symptoms,  595 
treatment,  592 
in  childhood,  440 
sjonptoms,  440 
treatment,  440 

Bradford  frame,  444 

Buck's  extension,  440 

Cabot    posterior    wire    splint, 

441 
plaster-of-Paris     spica     splint, 
440 
in  newborn,  439,  440 
neck  of.     See  Hip. 
prevention  of  resulting  deformities^. 

432,  433,  434 
prognosis,  435 
results,  436 

in  adult  life,  437 
in  childhood,  437 
in  old  age,  438 
shaft  of,  410 

measurement,  410 

Keen's  method,  413 
symptoms,  410 
subtrochanteric    fracture,    427 
symptoms,  428 
treatment,  428 
operative,   428 
supracondyloid  fracture,  429 
symptoms,  429 
treatment,  429 
treatment,  413 
ambulatory,  434 

Buck's  extension  apparatus  (mod- 
ified), 419,  420 
emergency  method,  413 
operative,  420,  421,  425,  426,  558 
transportation  of  a  patient,  414, 

415  .     ^ 

Fessler,  paralysis,  secondary,  m  frac- 
ture of  humerus,  216,  218 
Fiske,      ambulatory      treatment      at 

Roosevelt  Hospital,  638 
Fissure    of    Rolando,    indications    of 
lesions  about,  20 
of  skull,  25,  28 
Flail- joint,  shoulder,  188 
Flatfoot,  traumatic,  550 

treatment,  550 
Foot,  bones  of,  543 
astragalus,  543 
and  OS  calcis,  545 
metatarsal  bones,  551 


INDEX 


697 


Foot,  bones  of,  open  fracture  of  as- 
tragalus and  OS  calcis,  5  5 1 
operative    treatment,    551 
OS  calcis,  545 
phalanges,  553 
scaphoid  of  tarsus,  551 
Forearm,  bones  of,  284,  558 
CoUes'  fracture,  323 
olecranon,  311 

radius  and  ulna,  284,  295,  558 
Fossa,  anterior  middle,  44 
posterior,  44 
drainage  of,  44 
Fractures,  operative  treatment  of,  554 
method     of     operating     upon 

shafts  of  long  bones,  560 
results,  anatomical,  556 
non-operative  treatment  of,  556 

Gangrene   of   leg   after   fracture   of 
femur,  439 
in    separation    of     lower    femoral 

epiphysis,  447 
of  lower  leg,  499 

treatment,  499 
traumatic,  453 
Garre,  shortening  of  radius  and  ulna 

in  Volkmann's  contracture,   271 
Glycosuria  following  head  injury,  48 
Gocht  (quoted),  fractures  of  the  meta- 
tarsals, 609 
Goldstein,      paralysis,      primary,      in 

fracture  of  humerus,  216 
Gowers,  mortality  after  injury  to  first 

two  cervical  vertebrae,  102 
Greenstick  fractures  of  bones  of  fore- 
arm, 284 
treatment,  296,  310 
of  clavicle,  143,  144,  152 
of  femur,  neck  of,  408,  409 
treatment,  409 
Gunshot  fractures  of  bone,  585 

changes     in     construction     of 

modern  military  rifle,  585 
classification  of  parts  of  long 
bones  injured  (Kocher),  587 
comparison  of  old  and  modern 

bullets,  585,  591 
disinfection  of  limb,  594 
explosive  effect  of  bullet,  587 
factors  upon  which  amount  of 
damage  to  bone  is  depend- 
ent, 585 
resistance,  590 
revolution   of   bullet,    586 
shape  of  bullet,  585 
velocity  of  bullet,  587 
prognosis  in  fractures  of  femur, 

ricochet  bullet,  590 
treatment,  592 


Gunshot  fractures  of  bone,  treatment, 
592 
first  field  dressing,  593 
fracture  of  femur,  594 
infected  wounds,  594 
non-infected  wounds,  593 
operative,   595 
uncomplicated   injuries,    592 
wounds  of  entrance  and  exit,. 
590 
of    modern    projectiles    less 
grave,  592 
of  vertebrae,  119 


Hacker,  clinic  of,  splint  for  fracture 

of  humerus,  203,  204 
Head  injiury,  cases  of,  49 

injury  to  head,  five  days  later 
walks  about,  sudden  death, 

54 
middle  meningeal  hemorrhage, 

fracture  of  skull,  54 
open     depressed     fracture     of 
skull,    paralysis   of   one-half 
of  body,  52 
later  results,  47 

cerebral  abscess,  chronic,  48 
changes  of  character,  47 
epilepsy,  traumatic,  48 
headache,  chronic,  47 
insanity,  49 
vertigo,  47 
vomiting,  47 
Heel,  care  of,  in  treatment  of  fracture 
of  hip,  388 
of  leg,  504 

of  shaft  of  femur,  425 
of  Pott's  fracture,  532 
Hematoma  of  cartilaginous  septum  of 
nose,  63 
of  scalp,  25 
Hematomyelia,  112,  113,  115 
Hematuria,  94 

Hemorrhage,  extradural,  20,  22,  25 
consciousness,  interval  of,  20 
semiconsciousness,  period  of,  22 
unconsciousness,  20,  21,  24 
in  fracture  of  base  of  skull,  30,  3 1  >  32 
of  humerus,  198,  199 
of  leg,  500 

of  maxilla,  superior,  72 
of  ribs,  122 
into  pharynx,  32 

spinal  cord,  109,  112 
intracranial,  21,  38,  43 
sources,  21 

symptoms  of  compression,   21 
treatment,  39 
meningeal,  44 
middle  meningeal,  22,  43 


698 


INDEX 


Hemorrhage,  middle  meningeal,  cases  ' 
of,  with  fracture  of  skull,  49 
vs.  hemorrhagic  pachymeningi- 
tis, 35 
Hip  or  neck  of  femur,  376 
anatomy,  376 
fracture  in  adults,  377 
examination,  380 
impacted  and  unimpacted, 

385 

measurement,  382 
Bryant's  method,  383 

prognosis  and  result,  385 

results  after  fracture 
treated  by  immobiliza- 
tion, traction,  and  coun- 
tertraction,  386 

symptoms,  379 

treatment,  387 

general     considerations, 

387 
present  methods,  389 
fixation,  393 

lateral         pressure, 

398 
Thomas  hip-splint, 

389.  393 
forcible         abduction 
and  immobilization 
with     or      without 
traction  (Whit- 

man's        method), 
389,   398,   399.   401 
pegging,  389,  406 
traction,  389,  391 
after-care,  392 
fracture  in  childhood,  408 
immediate  result,  409 
late  result,  408 
symptoms,  408 
treatment,  409 

of    greenstick    fracture, 
408,  409 
Hot-air  treatment,  550 
Hot-water  bottles,  use  of,  40 

danger  from,  40 
Humerus,  160 

lower  end,  lesions  of,  227,  234 
fracture  of  external  condyle,  238 
of  internal  condyle,  238 
epicondyle,  238 
injury  to  lower  humeral  epiphysis, 

240,  558 
T-fracture  into  elbow-joint,   241 
transverse    fracture    above    con- 
dyles, 238,  254 
treatment,  254 
series  of  unselected  cases,  illustrat- 
ing   anatomical    and    functional 
results  five  years  after  accident, 
272 


Humerus,  shaft  of,  196 
after-treatment,  208 
fractures  in  the  newborn,  212 
musculospiral  nerve  in  fracture  of 

humerus,  213 
prognosis,  212 
symptoms,  196 
treatment,  199 

of  fractures  with  considerable 
displacement,   209 
with   little    or    no    displace- 
ment, 200 
after  treatment,  208 
operative,  209 
upper  end,  160 

after-care,  183,   188 
anatomy,   160 
diagnosis,  165 

dislocation    of    humeral    head, 
166 
subcoracoid,   166,  189 
subglenoid,   189 
examination  of  shoulder,  162 
fracture    of    anatomical    neck, 
167,  186 
of   surgical   neck,    177,    186, 
558 
prognosis  and  result,  184 
separation  of  upper  epiphysis, 
169,  186,  558 
prognosis,   177,   184 
treatment,  172,  176 
subperiosteal  fracture,  in  chil- 
dren, 178 
treatment,  178 

operative,   186,   188 

excision   of   shoulder-joint 
for  fracture  and  disloca- 
tion,     indications      for 
and  results  of,  188 
with  dislocation  of  upper  frag- 
ment, 186,  188 
treatment,  186,  188 
Huntington's  bone  staples,  561 

method    of   traction   and    counter- 
traction  in  treatment  of  fracture 
of  femur,  430,  43 1 
Hypernephroma,     metastatic,     as     a 

cause  of  fracture,  564 
Hysteroid  semiconsciousness,  24 


Ice-bags,  501 

Idiopathic  fragilitas  ossium,  568 
Ilium,  fracture  of  crest  of,  132 
Infection    in    compound   fracture 

skull,  28 
in  fracture  of  base  of  skull,  28 

of  humerus,  187 

of  leg,  485,  501 

of  maxilla,  inferior,  78 


of 


INDEX 


699 


Infection   in  fracture  of  maxilla,  su- 
perior, 71 
of  metacarpal  bones,  361 
of  metatarsal  bones,  551 
of  nasal  bones,  59 
in  gunshot  fracture  of  vertebrae,  119 
in  gunshot  wounds,  594 
in   open   fracture   of   phalanges   of 

hand,  373 
in  Pott's  fracture,  536 
in  separation  of  lower  femoral  ep- 
iphysis, -477 
Insanity  following  injuries  of  head,  49 
treatment,  operative,  49 

Jones,  acutely  flexed  position  in  re- 
duction of  fracture  of  elbow,  249 

Keen's  method  of  measuring  in  frac- 
ture of  shaft  of  femur,  413 
Kerr's  method  of  reducing  obstetric 

fracture  of  skull,  55 
Knee-jerks  in  fractures  of  vertebrae, 

105 
Kocher's  grouping  of  phenomena  in 
compression  of  brain,  19,  37 
classification  of  parts  of  long  bones 
injured  in  gunshot  wounds,  587 
external  lateral  incision,  use  of,  in 
unreduced  dislocations  of  elbow, 
676 
method  of  reducing  dislocation  of 
the  shoulder,  664 
Korsch's  treatment  of  thigh  fracture, 

636 
Krause,  quoted,  on  ambulatory  treat- 
ment of  fracture,  636 
advantages,  640 
limits  of  its  use,  637 
table  from  Paul  Bruns,  containing 
average  periods  of  healing,  641 

Laceration  of  brain,  18 
symptoms,  18,  19 
temperature,  19 
LaGarde  (quoted) ,  wounds  of  modern 

projectiles,  592 
Lane's  bone  plates  and  screws,  561, 

.562 
Leg,  481 

after-care,  516,  519 
anatomy,  481 
examination,  487 
general  observations,  484 
injury  to  tibial  tubercle,  485 
open  fractures,  514 
treatment,  514 

permanent  dressing,  514 
temporary  dressing,  514 
wound  of  soft  parts,  515 


Leg,  prognosis,  520 
results,  520 

re-fracture,  521 

thrombosis    and    embolism,    521 
symptoms,  490 
treatment,   494 

care  of  fracture  after  permanent 
dressing    has    been    applied, 
516 
of  heel,  504 

permanent  dressing,  502 
temporary  dressing,  501 
fractures    difficult    to    hold    re- 
duced, 511 
operative  treatment,  5 1 1 
with    considerable    immediate 

swelling,  498 
with   little   or   no   swelling   or 
displacement,  495 
operative  treatment  of  old  frac- 
ture of  leg  near  ankle,  538 
Lesions   following   injury   to   definite 
vertebrae,  table  of,  93 
to  shoulder,  272 
Ligaments,    lesions    of,    in   backward 
dislocation    of    first    proximal 
phalanx  of  thumb,  680 
in  dislocation  of  acromioclavicu- 
lar joint,  658 
Limitation    of    motion    after    CoUes' 
fracture,  351 
after  fracture  of  elbow,  265 
of  hmnerus,  168,  190 
of  olecranon,  321 
of  patella,  474 
of  radius,  286 

and  ulna,  307 
of  scaphoid  bone  of  wrist,  360 
after  open  fracture  of  astragalus 

and  OS  calcis,  551 
after  operation  for  unreduced  dis- 
location of  shoulder,  190 
after  separation  of  lower  femoral 

epiphysis,  453 
of  jaw,  in  fracture  of  malar  bone, 
67,  68 
Little's  disease,  271 
Littlewood,  cause  of  Volkmann's  con- 
tracture, 269,  271 
Lorenz,  perineal  band  in  fracture  of 

hip,  404 
Lothrop's    method    of    elevating    de- 
pressed malar  bone,  72,  74 
technique  in  operating  for  deform- 
ity following  Colles'  fracture,  353 
Lovett  (quoted),  pupils,  in  fracture  of 
base  of  skull,  30 

MacCormac  (vSir  William)  (quoted), 
treatment  of  gunshot  fracture  of 
femur,  596 


700 


INDEX 


Makins  (George  Henry),  quoted,  am- 
putation for  suppurating  frac- 
tures, 597 
difficulties  of  frequent  dressing  of 

gunshot  fractures,  594 
gunshot  fractures  of  femur,  595 
wounds  in  South  African  War, 
587.  588 
prognosis    in    fracture    of    femur 
(quoted    from    "Surgical    Ex- 
periences"), 597 
Malar  bone,  67 

complications,  67 
examination,  67 
symptoms,  68 
treatment,  70 
operative,  71 
Martin     (Dr.     Edwin),     ambulatory 
treatment,  cases  reported,  562,  638 
Mason,    excisions    of    shoulder-joint, 

cases  of,  189,  190 
Massachusetts  General  Hospital,  cases 
treated  at,  430 
case  results  after  fracture  of  femur, 
436,  437 
of  leg,  520 
of  patella,  474 
of  excision  of  shoulder-joint  for 
fracture  and   dislocation,    188, 
189,  190 
of  musculospiral  paralysis,  opera- 
tion for,  in  fracture  of  humerus, 
225 
statistics     concerning     ambulatory 
treatment,  641 
Massage  after  dislocation    of   elbow, 
675 
of  thumb,  680 
after  fracture  of  clavicle,  151 
of  elbow,  260,  261 
of  femur,  shaft  of,  433,  434 
of  humerus,  184,  188,  211,  223 
of  leg,  518 

of  metacarpal  bones,  372 
of  olecranon,  320 
of  patella,  470,  474 

with  operative  treatment,  462 
of  radius,  289,  291 

and  ulna,  306 
of  ribs,  126 

of  scaphoid  bone  of  wrist,  355,  361 
of  scapula,  159 
after  Pott's  fracture,  534 
after   separation   of   lower   femoral 

epiphysis,  453 
for  traumatic  flat-foot,  550 
in  CoUes'  fracture,  349,  351 
in  fracture  of  astragalus,  549,  550 

of  OS  calcis,  550 
in  Volkmann's  contracture,   271 
Matas'  splint,  90 


Materials  for  ordinary  care  of  closed 

fractures,  643 
Mauser  bullet,  592 

revolution  of,  592 
size,  weight,  and  velocity,  592 
Maxilla,  inferior,  74 
abscesses,  87 
examination,  76 
fracture  of  body  of  jaw,  78 

of  coronoid  and  articular  proc- 
esses,  90 
of   ramus,   just   behind   molar 

teeth,  85 
fracture  of  ramus  upon  same 
or  opposite  sides,  86 
symptoms,  76 
treatment,  77 
superior,  71 

after-care,  73,  74 
complications,  72 
diagnosis,  71,  72 
treatment,  72,  73 
Maxwell  (quoted),  reduction  of  frac- 
ture of  hip,  391 
McBurney-Porter    hook      manoeuver 
in  reducing  a  dislocated  shoulder, 
'■  188 
McGraw's    method    of    reducing    old 
irreducible  dislocations  of  the  jaw, 

654 
Measurement  in  Colles'  fracture,  326 
in  dislocation  of  humeral  head,  167 
in  fracture  of  elbow,  229 
of  femur,  neck  of,  382 

shaft  of,  410 
of  humerus,  164 

of  external  condyle,  164 
of  leg,  487 
in  Pott's  fracture,  526 
in  T-fracture  into  elbow-joint,  241 
Mental   rest  following  head   injuries, 

48 
Metacarpal  bones,  361 
symptoms,  361 
treatment,  362 
Metatarsal  bones,  551 
complications,  552 
open  fracture,  553 
symptoms,  551 
treatment,  553 
Meyers  (quoted),  fracture  of  neck  of 

femur  in  childhood,  408 
Mixter  and  Osgood,  review  of  litera- 
ture of    injuries  to   atlas   and 
axis,  102 
treatment,  operative,  103 
Mixter's  case  of  fracture  of  vertebrae 
with     transverse    lesion    of    cord, 
quoted,  no 
Moriarity     leather     chin     splint     in 
fracture  of  inferior  maxilla,  86 


INDEX 


701 


Morphin,  use  of,  510 

Mortality  in  fracture  of  base  of  skull, 

46 
Mosher,   elevation  of   nasal  bone   in 
fracture  of  nose,  62 
plates    of    septum,    in    fracture   of 

nose,  60 
(quoted),  correction  of  lateral  de- 
formity of  nasal  bones   following 
old  fractures,  65 
Mouchet,  illustration  of  displacement 

in  fracture  of  neck  of  radius,  353 
Munro,  quoted,  pupils  in  fracture  of 

base  of  skull,  30 
Murphy    (quoted),    operative    treat- 
ment of  fresh  fracture;  of  olecranon, 
320 
Musculospiral    nerve   in   fracture    of 
humerus,  196,  213,  216,  217 
anatomy  of,  215 
etiology,  217 
prognosis,  219 

symptoms    of    compression, 
216,  217,  218 
of  contusion,  216 
treatment,  220,  221 
electrical,  221 
operative,    220,    221,    222 
Rontgen  ray,  221 
Myeloma  as  a  cause  of  fracture,  564 


NancrEdE  (quoted),  585 

amputation  of  long  bones,  594 
deflection     of     bullet     in     gunshot 
wounds,  590 
Nasal  bones,  56 

fractures  of,  58 
anatomy,  56 
complications,  59 
in   combination  with   fracture 
of  septum,  60 
prognosis,  64 
symptoms,  38 
treatment,  61 
old  fracture,  65 

septum,  abscess  of,  64 
treatment    (Mosher),    65, 

66 
dislocation,  61 
hematoma,  63,  64 
horizontal  fracture,  60 
in  fracture  of  nose,  64 
lesions,  61 

sigmoid  deviation,  61 
vertical  fracture,  60 
Necrosis    after  fracture  of   humerus, 
with  dislocation  of  upper  frag- 
ment,  188 
of  maxilla,  inferior,  77 
superior,  72,  90 


Necrosis  after  an  open  fracture  of  leg, 
520 
after   separation   of   lower   femoral 

epiphysis,  447 
in    open     fracture    of    metatarsal 
bones,  553 
of  phalanges,  375 
ischemic,  267 
Nephritis  after  fractures  of  vertebrae, 

119 
Nerves,  lesions  of,  following  head  in- 
juries, 30,  47,  48,  49 
in  fracture  of  laase  of  skull,  30,  31,32 
of  floor  of  orbit,  68 
of  humerus,   196 
of  leg,  484 
of  malar  bone,  68 
of  maxilla,  superior,  72 
of  vertebrae,  94 
in  separation  of  lower  femoral  ep- 
iphysis, 447 
of  spinal  cord,  anatomy  of,  92,  93, 

94 
Neugebauer,  massage  and  electricity 

in  musculospiral  paralj'sis,  223 
Neuralgia,  occipital,  103 
Neuritis  following  injury  to  musculo- 
spiral nerve,  196 
Newborn,  fractures  in  the: 
of  femur,  439 
of  humerus,  212 
of  skull,  55 
Nichols   (quoted),   pupils  in  fracture 

of  base  of  skull,  30 
Non-operative  treatment  of  fractures, 

554 
Non-union  of  fracture  of  clavicle,  154 
operative  treatment,   154 
of  femur,  neck  of,  385 
of  humerus,  196 
of  leg,  538 

of  phalanges  of  hand,  373,  375 
of  fractures,  307 
causes,  310 
treatment,  310 
operative,  310 
Nose,  dangers  of  blow  upon,  38 

deformity  of,  from  fracture,  38,  61, 
64 
from  syphilis,  38 
von  Nussbaum  (quoted),  first  dressing 
of  gunshot  wounds,  593 


Obstetric  fractures  of  humerus,  212 
of  skull,  55 
causes,  55 
prognosis,  55 
treatment,  55 
Olecranon,  31 1 
after-care,  320 


702 


INDEX 


Olecranon,  anatomy,  311 
process,  312 

summary  of  treatment,  322 
symptoms,  315 
treatment,   316 

in  open  fracture,  318 
operative,  318 

of  fresh  fracture,  320 
Operative  treatment  of  fractures,  554 
Orbit,  involvement  of,  in  fracture  of 

malar  bone,  68 
Orbital  plate  of  frontal  bone,  31 
Os  calcis,  545 

open  fracture,  551 

operative  treatment,  551 
results,  551 

flatfoot,  550 
symptoms,  545 
treatment,  547 
Osgood     (quoted),    injury    to    tibial 
tubercle,  487 
and  Mixter,  review  of  literature  of 
injuries  to  atlas  and  axis,  102 
treatment,  operative,  103 
and  Penhallow,  splint  for  fracture 
of  humerus,  203,  204,  205 
Osteogenesis  imperfecta,  568 

prognosis,   570 
Osteomalacia  as  a  cause  of  fracture, 

567 
Osteomyelitis  as  a  cause  of  fracture, 
565 
infectious,  565 

treatment,  566 
tuberculous,  567 

Pachymeningitis,    hemorrhagic    in- 
ternal, 33,  35 
symptoms,  35 
Pad  under  instep    after    Pott's  frac- 
ture, 529 
Pad,  V-shaped,  in  fracture  of  humerus, 

182,  202 
Padding  in  Colles'  fracture,  345 
in  fracture  of  femur,  421 
of  metacarpal  bones,  361 
of  OS  calcis,  547 
in  Pott's  fracture,  529 
of  Dupuytren  splint,  527 
Painter    (quoted),    case    of    fracture 
caused   by   infectious   osteomye- 
litis, case  of  osteomalacia,  568 
Paralysis  in  fracture  of  humerus,  164, 
226 
of  skull,  24 

of  vertebrae,  94,  98,  100,  loi,  102, 
105 
in  unconsciousness  from  apoplexy, 

34 
in    Volkmann's    contracture,    266, 
270,  271 


Paralysis,  obstetrical,  212 

of  musculospiral  nerve,  196,  213 
facts  of  importance,  226 
primary,  216,  217,  218,  221,  222 
secondary,  216,  217,  218,  220, 
223 
of  peripheral  nerves,  270 
Passive   motion   after    dislocation   of 
elbow,  259,  675 
of  shoulder,  667 
of  thumb,  680 
after  fracture  of  clavicle,  144,  150 
of  elbow,  259,  260 
of  femur,  shaft  of,  433 
of  humerus,  211,  212 
of  leg,  518 
of  olecranon,  321 
of  patella,  469 
of  radius,  291 

and  ulna,  306 
of  scaphoid  bone  of  wrist,  355 
with  operative  treatment,  479 
after  Pott's  fracture,  533 
after  separation  of  lower  femoral 

epiphysis,   453 
in  CoIIes'  fracture,  349,  350 
in  fracture  of  astragalus,  551 
Patella,  456 
anatomy,  456 
old  fracture,  480 
open  fracture,  471 

treatment,  472 
operative     interference     in     recent 
closed  fractures,  477 
conditions  suitable,  478 
danger  of  sepsis,  478 
indications,  479 
method  of  operation,  479 
restoration  of  function  of 
joint     following    opera- 
tive treatment,  479 
prognosis,  472 
results,  474 
symptoms,  459 
treatment,  461 

limitation   and  removal  of  effu- 
sion, 461 
maintenance   of   reduction   until 

union  is  satisfactory,  465 
operative,  480 
reduction  of  fragments,  463 
restoration  of  function  of  joint, 

467 
summary  of  treatment  by  expec- 
tant or  non-operative  method, 
470 
Pathologic  fractures,  564 

idiopathic  fragilitas  ossium,  568 
osteogenesis     imperfecta,     568 
symptomatic    fragilitas    ossium, 
564 


INDEX 


703 


Pathologic     fractures,     symptomatic 
metastatic  carcinoma,  564 
osteomalacia,  567 
osteomyelitis,    infectious,    565 

tuberculous,   567 
rachitis,  568 
syphilis,  567 
syringomyelia,   567 
tabes  dorsalis,  567 
Paul,   union   of   bone   in   fracture   of 
femur,  433 
of  leg,  518 
and  Scudder,   musculospiral   nerve 
in  fracture  of  humerus,  213 
Pelvis,  130 

complications,  132,  135,  139 
rupture  of  urethra,  135 

of  urinary  bladder,  138 
visceral  lesions,  135 
examination,  130,  131 
prognosis,  140 
treatment,  132 
Penhallow    and    Osgood,    splint    for 
fracture  of  humerus,  203,  204,  205, 
208 
Phalanges,  553 
of  the  foot,  553 

treatment,  553 
of  the  hand,  373 
open  fractures,  375 

operative  treatment,  375 
symptoms,  373 
treatment,  373 
Pharyngeal     mucous     membrane    in 

fracture  of  base  of  skull,  30,  32 
Pilch er    (E.    S.),    ambulatory     treat- 
ment, cases  reported,  638 
Plaster-of- Paris,   employment  of,   73, 
614 
application  to  patient,  116,  512, 

631 
dextrin  bandage,  634 
making  of  bandages,  617,  618 
removal  of  the  plaster  splint,  634 
rolling  the  plaster,  614 
jacket,  115 

method  of  applying,  116 
roller  bandage,  614 

method  of  making,  614 
splint,  297,  310,  440,  465,  512 
removable,   465 
spica,  440 
traction,  512 

method  of  application,  512,  634 
shoulder-cap,   1 8 1 

support  in  abduction  of  hip  (Whit- 
man's method,)  398 
Pleurisy  in  fracture  of  ribs,  122,  126 
Pneumonia,  hypostatic,   104,  389 
Pneumothorax    in    fracture   of    ribs, 


Poland,  John  (his  "Traumatic  Sepa- 
ration of  the  Epiphysis,"  quoted), 

571 
Poliomyelitis,  anterior,  271 
Pool    (quoted),   treatment   of   CoUes' 

fracture,  345 
Porter,  illustration  of  fracture  of  head 

of  radius,  287 
Porter  and  McBurney  hook,  666 
Pott's  fracture,  521 
anatomy,  521 
lesions  which  may  be  present,  521, 

522 
open  fracture,  536 

treatment,  536,  537 
operative  treatment  of  old  frac- 
tures, 538 
prognosis  and  results,  535 
symptoms,  523 
treatment,  527 

care  after  permanent  dressing 

is  applied,  533 
Diipuytren  splint,  529 
lateral   and   posterior   plaster- 
of-Paris    splints     (Stimson's 
splint),  532 
operative,  538 

indications,  538,  539 
posterior     wire     splint      with 

curved  foot-piece,  530 
support  of  arch  of  foot,  535 
Pressure  sores,  388 

treatment,  388 
Pubic  portion  of  ring  of  pelvis,  132 
Pulse  in  alcoholic  coma,  35 

in  coma  from  opium-poisoning,  33 
in  fracture  of  hip,  388 
of  leg,  490 
of  skull,  18,  19 
in  unconsciousness  in  uremia,  34 
Puncture,  lumbar,  37 
Pupils  in  alcoholic  coma,  35 

in  coma  from  opium-poisoning,  33 

in  fracture  of  base  of  skull,  30 

in  unconsciousness  from  apoplexy, 

34 
in  uremia,  34 
Pyelitis    after   fracture   of    vertebrae, 
104,  119 


QuiNBY   (quoted),  results  after  frac- 
ture of  patella,  476 


Rachitis  as  a  cause  of  fracture,  568 
Radio-ulnar   joint,    inferior,    involve- 
ment of,  in  Colles'  fracture,  351 
Radius,  fracture  of  neck  or  head,  238, 
258,  285 
complications,  286 


704 


INDEX 


Radius,    fracture    of    neck    or    head, 
diagnosis,  285 
prognosis,  288 
symptoms,  286 
treatment,  289,  303 
operative,   290 
of  shaft,  292,  558 
symptoms,  292 
treatment,  296,  304 
operative,  304 
of  open  fractures,  304 
and  ulna,  284,  558 

incomplete  or  greenstick  fracture, 

284,  310 
prognosis  and  result,  307 
symptoms,  284 
treatment,  296,  310 
Reflexes  in  coma  from  opium-poison- 
ing, 33 
in  fracture  of  vertebrae,  94,  loi,  105, 
III 
Reithus,  case  of  musculospiral  paraly- 
sis, 220 
Refracture    of    bones    of    the    lower 

extremity,  521 
Respiration  in  alcoholic,  35 

in  coma  from  opium-poisoning,  33 
in  fat  embolism,  454 
in  fracture  of  hip,  388 
of  ribs,  121 
of  skull,  19 
of  sternum,  127 
of  vertebrae,  loi 
in  intracranial  lesions,  39 
in  unconsciousness  from  apoplexy, 

34 
in  uremia,  33 
Rest,  importance   of,   after  head    in- 
juries, 42,  48,  45 
Retention   and   incontinence  in   con- 
cussion of  brain,  18 
in  fracture  of  vertebrae,  94 
Rheumatism,  chronic,  184,  385 
Ribs,  121 

after-treatment,   126 
anatomy,  121 
complications,  122 
examination,  121 
symptoms,  121 
treatment,   123 
operative,  126 
Ridlon  (quoted),  Thomas'  hip-splint, 

393 
Roberts,  ambulatory  treatment,  638 
Robinson,  splint  for  fracture  of  thumb, 

369,  370,  372 
Rontgen  ray  and  its  relation  to  frac- 
tures, 598 
assistance  in  diagnosis,  605,  606 

in  examination,  605,  606 
Crookes'  tube,  599 


Rontgen  ray,  effects  of  x-rays,  extent 
of,  600 

accuracy    and    inaccuracy    of 
pictures,  604,  605 

distortion  of  shadows,  600 
fluoroscope,  599,  607 
forms  of  fracture  in  which  .T-ray 
gives  great  assistance,  606 

elbow-joint,  607 

femur,  608 

foot,  bones  of,  609 

leg,  lower,  609 

patella,  603 

shoulder-joint,   607 

wrist,  608 
in  knowledge  of  pathology  and 

treatment  of  fractures,   605 
medicolegal   relations   of   x-rays, 

conclusions     expressing    views 

of  American  Surgical  Associa- 
tion,   adopted   in   May,    1900, 

611 
use  in  demonstrating  to  students, 

606 
use  of,  as  a  method  of  record  in 

rare  fractures,  606 
x-ray  burns  and  dermatitis,  609 

picture  and  photograph,  com- 
parison of,  599 
in  diagnosis  of   CoUes'   fracture, 

335,  339,  343 
of  coronoid  process  of  ulna,  286 
of  elbow,  227 
of  femur,  neck  of,  376 
of  fracture  of  astragalus,  543 
of  humerus,  165,  168,  178,  221 
of  pathological   fractures,   564 
of  radius,  neck  and  head  of,  285 
of  scaphoid  bone  of  wrist,  355, 
361 
in  dislocation  of  shoulder,  165 
in  gunshot  fractures,  585 
in  knowledge  of  epiphyses,  607 
in     unreduced     dislocations     of 
shoulder,  668 
Ruptured  artery,  196 


Sand-bags,  391 

Sarcoma  as  a  cause  of  fracture,  564 

Sayre  dressing  (modified)  in  fracture 

of  clavicle,  148,  151 
Scaphoid  bone  of  wrist,  355 
acute  fracture,  355 

chronic  cases,  359 
diagnosis,  359 
treatment,  359 
operative,   360 
Scapula,  155 

acromial  process,  157,  159 
body  of,  155 


INDEX 


705 


Scapula,  neck  of,  157,  158 

treatment  in  general,  158 
Senn  (quoted),  lateral  pressure,  585 
Sepsis.     See  Infection. 
Septicemia,  454 

Shock  after  fracture  of  femur,  neck 
of,  376 
shaft  of,  595 
of  pelvis,  135 
of  rib,  121 

of  superior  maxilla,  71 
of  vertebrae,  94,  104,  119 
after  rupture  of  urinary  bladder,  139 
after  separation   of   lower  femoral 

epiphysis,  447 
in  fracture  of  skull,  36,  38 
in  gunshot  fracture  of  femur,  590 
Short-Desault  apparatus,  512 
lyovett's  adaptation,  412 
Shortening  of   bone   after  separation 
of  lower  femoral  epiphysis,  449 
in  fracture  of  femur,  neck  of,  383 

shaft  of,  425 
of  humerus,  184 
of  leg,  487,  488 
Silver-fork  deformity,  327 
Simmons  (quoted),  prognosis  of  osteo- 
genesis imperfecta,  570 
Skull,  17,  23,  24 

cases  of  head  injury,  49 
child's,  peculiarities  of,  39 
compression  of  brain,  19,  20 
concussion  and  contusion  of  brain, 

17 
diagnosis,  37 

examination  of  patient,  36 

general  condition,  36 

local  condition,  37 

extradural  hemorrhage,  20 

fracture  of  base,  25,  28,  30 

of  vault,  25 
general  observations,  38 
laceration  of  brain,  18 
later  results  of  injuries  to  the  head, 

47.  48,  49 
nature  of  fracture,  24 
obstetric  fractures,  55 
prognosis,  45 

subarachnoid  serous  exudation,  24 
treatment,  39 

of  ear,  41 

of  mouth,  41,  42 

of  nose,  41 

of  scalp,  41 

operative,  40,  42,  43,  44 
unconsciousness      resulting      from 

other  than  surgical  causes,  32 
Sling  after  dislocation  of  shoulder,  667 
for  Colles'  fracture,  347 
for  fracture  of  anatomical  neck  of 

humerus,  169 

45 


Sling  for  fracture  of  clavicle,  141,  144 
of  elbow,  227 
of  humerus,  shaft  of,  206,  207 

upper  end,  169,  181 
of  radius  and  ulna,  298,  302,  305 
of  scapula,  159 
Smith  anterior  wire  splint,  511 
Spinal  cord,  anatomy,  92 
lesions  of,  92,  93 
how  to  localize,  93 
operative  treatment,   109,  no 
prognosis,  98,  104 
transverse,  105 
and  partial,   105 

how  to  distinguish,   105 
Spine,  injury  to,  examination,  94 
Splints,  making  of: 
leather,  86 
plaster-of-Paris,  297 
for  Colles'  fracture,  345 
for  fracture  of  astragalus,  543,  547 
of  elbow,  244,  255 

internal  right  angle,  255 
right-angle     internal    angular, 
244 
of  femur,   shaft  of,   coaptation, 
202,  206,  419 
emergency,  415 
ham  splint,  419 
T-splint,  420 
wooden,  419 
of  hip,  Thomas  hip-splint,  393 
traction  hip-splint,  392 
T-splint,  391 
of  hmnerus,  coaptation,  181,  202, 
207,  208,  209 
internal  angular,  208 
internal  right-angle,  208 
plaster-of-Paris,   176,   181,  209 
after-care,  211 
of  leg,  light  plaster,  514 
pillow  and  side,  501 
plaster-of-Paris,  501,  511 
posterior  wire  and  side,  503 
Smith's  anterior  wire,  511 
of  maxillary   bones,   buckle  and. 
strap,  86 
chin-piece,  82 
dental,  78 

making,  78,  83 
Matas',  90 
silver-wire,  79 
of  metacarpal  bones,  372 
of  metatarsal  bones,  551,  553 
of  nasal  bones,  62 
Cobb's,  62 
Coolidge's,   63 
tin,  62 
of  olecranon,  311 

internal   right-angle,   316,   322 
long  internal,  317 


7o6 


INDEX 


Splints  for  fracture  of  os  calcis,  545 
of  patella,  456 

in  open  fracture,  471,  472 
of  phalanges  of  foot,  553 

of  hand,  374 
of  radius,  neck  of,  304 
and  ulna,  296 

after-care  of  wooden  and  tin 

splints,  303 
in  greenstick  fractures,   310 
internal    right-angle    (of    tin), 
304 
omission  of  splints,  310,  311 
method   of  application,   302 
after-care,  298 
plaster-of- Paris,    297,    310 
precautions  in  using,  297 
palmar  and  dorsal  (of  wood), 
300 
for  Pott's  fracture,  528 
Dupuytren,  527,  529 

lateral  and  posterior  plaster- 
of- Paris  (Stimson's  splint), 
.532 
pillow  and  side,  527 
posterior   wire   with  curved 
foot-piece,  530,  535 
Sponge  compresses,  461 
"Spontaneous  fracture,"  564 
Sprain  of  wrist,  335 
Starr    (quoted),  fracture   of   neck    of 

femur  in  childhood,  408 
Sternum,  127 

complications,  127,  128,  129 
diagnosis,  128 
treatment,  128 
operative,  129 
Stimson    (quoted),   reduction   of  dis- 
locations, 674 
Stimson's  splint,  532 
application,  532 
making  of,  532,  533 
Stone  (J.  S.)   (quoted),  subperiosteal 
fractures  of  upper  end  of  humerus  in 
children,  178 
Subarachnoid  serous  extravasation,  37 

exudation,  24 
Subjugation  of  head  of  radius,  293 
Subluxation  of  head  of  radius,  286 
Sunstroke  following  head  injuries,  48 
Surgical  neck  of  humerus,  177 

after-treatment     of     operated 

cases,   1 88 
fracture    with    dislocation    of 

upper  fragment,  186 
oblique    fracture    with    great 

displacemrnt,  186 
treatment,   186 

operative,  186,  187 
Suturing  fracture  of  clavicle,  144,  150, 
153 


Suturing  fracture  of  hiunerus,  196 

shaft  of,  187 
surgical  neck  of,  177 
of  jaw,  71,  72,  74,  76 
of  leg,  500 
of  patella,  472,  477 
of  radius  and  ulna,  320,  354 
in  dislocation  of  hiuneral  head,  187 
results,  187 
Symptomatic  fragilitas  ossium,  564 
Synovial  membranes,  583,  584 
Synovitis,  traumatic,  of  ankle,  522 
of  elbow-joint,  316 
of  knee,  459 
Syphilis  as  a  cause  of  fracture,  567 
Syringomyelia  as  a  cause  of  fracture, 
567 


Tabes  dorsalis  as  a  cause  of  fracture, 

567 
Table  stating  lesions  following  injury 

to  definite  vertebrae,  93 
Taylor  hip  traction  splint,  406,  434 

steel  back  brace,  129 
Teeth  after  fracture  of  maxillae,  77-90 
Temperature  in  alcoholic  coma,  35 
in  alcoholic  delirium,  35 
in  coma  from  opium  poisoning,  33 
in  fracture  of  skull,  18,  19,  36 
in  fracture  of  vertebrae,  112 
in  intracranial  lesions,  38,  39 
in  laceration  of  brain,  35,  38 
in  rupture  of   urinary  bladder    in 

fracture  of  pelvis,  139 
in  unconsciousness  from  apoplexy, 

34 
in  uremia,  34 
Temporal  bone,  petrous  portion  of,  31 

glenoid  fossa  of,  29 
Tenotomy  of  tendo  Achilles,  429,  511 
Tetanus  following  fracture,  323 

treatment,  323 
T-fracture  into  elbow-joint,  241 

into  knee-joint,  559 
Thomas,    illustration   of    fracture   of 
head  of  radius,  288,  289 
(quoted),  treatment  of  fracture  of 
neck  or  head  of  radius,  255,  289 
hip-splint,  393 
application,  393 
description,  393 
knee-splint,  636 
Thomson   (Prof.   Klihu)   (quoted),  ef- 
fects of  x-rays  on  the  tissues,  a  per- 
sonal experiment,  610 
Three  bony  points  of  elbow  region,  228 

palpation  of,  228 
Thrombosis,  521 
Tibial  tubercle,  injury  to,  485 
symptoms,  486 


INDEX 


Tibial  tubercle,  injury  to,  treatment, 
487 
operative,  487 
Treatment  of  fractures,  operative,  554 
method     of     operating     upon 

shafts  of  long  bones,  560 
results,  anatomical,  556 
non-operative,  555 
Trendelenburg,  division  of  olecranon 

676 
Trephining  the  skull,  45,  48 
Treves,  gunshot  fracture  of  bone,  585 
T-splint,  132,  391 


TJi^NA,  coronoid  process  of,  286,  296, 
304 
shaft  of,  295,  558 

treatment,  296,  304,  306 
Unconsciousness  from  apoplexy,  34 
in  extradural  hemorrhage,  20,  21,  24 
in  intracranial  hemorrhage,  38 
in  uremia,  33 
"Union  of  bones,  time  necessary  for : 
after  separation  of  lower  femoral 

epiphysis,  445,  584 
in  Colles'  fracture,  323 
in  fracture  of  astragalus,  543 
of  clavicle,  152 
of  elbow,  227 

of  femtu",  shaft  of,  432,  433 
of  humerus,  184,  207,  212 
in  childhood,  212 
in  the  newborn,  212 
of  ilium,  132,  140 
of  leg,  518 
of  malar  bone,  57 
of  maxilla,  inferior,  74 

superior,   7 1 
of  metatarsal  bones,  551 
of  olecranon,  321 
of  patella,  456 
of  phalanges  of  hand,  373 
of  radius  and  ulna,  284 
of  ribs,   121 
of  scapula,  159 
of  sternum,  127 
in  greenstick  fracture  of  bones  of 

forearm,  310 
in  refractures,  310 
after   pathologic   fractures,    564, 
568 
Ununited  fracture.     See  Non-union. 
Uremia  in  fracture  of  skull,  36 
Urethra,    injury    to,    in    fracture    of 
pubic  bone,   132 
rupture  of,  in  fracture  of  pelvis,  135, 
136,  138,  139 
extravasation,  136 
mobilization,  138,  139 
symptoms,  135,  136 


707 

Urethra,    rupture   of,  in  fracture  of 

pelvis,  treatment,  138,  139,  140 
Urotropin  in  fracture  of  skull,  40,  41 

Vault  of  skull,  25 
Velpeau  bandage  in  fracture  of  clav- 
icle, 150 
Vertebrae,  91-120 
anatomy,  91 
cervical,  92 
dislocations,  92 

injuries     to     cervicodorsal     region 
opposite     cervical     enlargement 

of  spinal  cord,  loi 
to  dorsal  vertebrae,  100 
to  first  two  cervical  vertebrae,  102 
fracture  of  odontoid  proc- 
ess, 103 
diagnosis,    103 
early  symptoms,    103 
later  symptoms,  103 
to  last   dorsal  and  lumbar  ver- 
tebrae, 98 
to  midcervical  region,    loi,    102 
examination  of  injury  to  spine,  94 
general  symptoms  common  to  frac- 
tures, 94 
gunshot  fractures,  119 

treatment,   119,  120 
lesions,  table  of,  93 
prognosis,  104,  112 
symptoms  of  fracture  of  different 
regions  of  spine,  cord  being  in- 
volved, 98 
treatment,  105,  119 

operative,  108,  109,  no 
plaster-of-Paris  jacket,  115 

method  of  applying,   116 
summary,  119 
Vertical    suspension    in    fracture    of 

thigh  in  childhood,  444 
Vertigo,  47 
Visceral  lesions  in  fracture  of  pelvis, 

135 
of  vertebrae,  gunshot,  119,  120 
Volkmann's  contracture,  266 
cause,  267 

illustrative  case,  268 
prognosis,   265 
symptoms,  270 
treatment,  271 
operative,  271 
Vomiting  following  head  injuries,  47 
V-shaped  pad  in  fracture  of  humerus, 
181,  202 

Walton  (quoted),  hysteroid  semicon- 
sciousness, 24 
reduction  of  dislocation  of  cervical 
vertebrae,  94,  650 


7o8 


INDEX 


Walton,  spinal  cord,  transverse  lesion 

of,  III 

Warbasse,  ambulatory  treatment 
(Bollinger's  method),  637 

"Watery  discharge  from  nose  or  ear 
ia  fracture  of  base  of  skull,  32 

Whitman  (quoted),  fracture  of  neck 
of  femur  in  childhood,  408 

Whitman's  method  of  treating  frac- 
ture of  hip,  398 

Wiring  fractured  bones  of  jaw,  74, 
79 


Wiring  fractured  bones  of  olecranon^ 
320 
of  pelvis,  132 
teeth  together  in  fracture  of  jaw,  79 
Woodbury,  ambulatory  treatment  at 

Roosevelt  Hospital,  638 
Woolsey,  ambulatory  treatment,  638 
Wounds  of  open  fractures,  cleansing, 

514 
Wrist,  dislocation  of,  backward,  337 

sprain  of,  335 
Wrist-drop,  196 


RDlOl 


C«»-i/1i^jaT» 


Scu2 
1911 


"'"he  treatment  of  fractures, 


2002101696 


